Attachment integrated claims systems and operating methods therefor

ABSTRACT

Systems and methods for processing textual messages which are integrated with one or more digital attachments is described. These systems and methods are useful in the electronic filing and processing of, for example, image data, and of textual data associated with the image data. One particular application of these systems and methods would be for the electronic filing and processing of dental x-rays with patient claim forms.

RELATED APPLICATIONS

This application is a Continuation of U.S. patent application Ser. No.10/196,122 filed Jul. 17, 2002 now U.S. Pat. No. 7,178,020; which is aContinuation of U.S. patent application Ser. No. 10/036,432 filed Jan.7, 2002 (now U.S. Pat. No. 6,480,956); which is a Continuation of U.S.patent application Ser. No. 09/592,256 filed Jun. 12, 2000 (now U.S.Pat. No. 6,338,093); which is a Continuation of U.S. patent applicationSer. No. 09/232,805 filed Jan. 19, 1999 (now U.S. Pat. No. 6,076,066);which is a Continuation of U.S. patent application Ser. No. 08/824,010filed Mar. 25, 1997 (now U.S. Pat. No. 6,003,007); which each claimsPriority from Provisional Application Ser. No. 60/014,427 filed Mar. 28,1996. This application is further a Continuation of U.S. patentapplication Ser. No. 09/961,308 filed Sep. 25, 2001 now U.S. Pat. No.7,409,632; which is a Continuation of U.S. patent application Ser. No.09/745,489 filed Dec. 26, 2000 (now U.S. Pat. No. 6,343,310); which is aContinuation of U.S. patent application Ser. No. 08/823,977 filed Mar.25, 1997 (now abandoned), and U.S. patent application Ser. No.08/823,978 filed Mar. 25, 1997 (now abandoned), and is further aContinuation of U.S. patent application Ser. No. 09/587,284 filed Jun.5, 2000 (now U.S. Pat. No. 6,199,115) as a Continuation of U.S. patentapplication Ser. No. 09/232,805 filed Jan. 19, 1999 (now U.S. Pat. No.6,076,066) as a Continuation of U.S. patent application Ser. No.08/824,010 filed Mar. 25, 1997 (now U.S. Pat. No. 6,003,007); which eachclaims Priority from Provisional Application Ser. No. 60/014,427 filedMar. 28, 1996. Each of the foregoing applications is commonly assignedand incorporated by reference herein in their entirety.

BACKGROUND OF THE INVENTION

The present invention relates generally to an attachment integratedclaims (AIC) system for preparing and processing forms with integratedattachments. More specifically, the present invention relates to an AICsystem for preparing and processing digital insurance claims includingPrior Approval Claim (PAC) Applications containing both a text form andan integrated digitized attachment. A method of operating a totallydigital AIC system is also disclosed.

High administrative costs for filing and processing health insuranceclaims have been the bane of the health insurance industry from itsinception. Over the years, many attempts have been made to develop afaster and more cost effective claims processing system. Three stages inthis development effort are described in the following correspondinglynumbered paragraphs.

(1) The original system involved hard copy paper claims only, withtransmission and all processing done manually. Originally, an insuranceclaim was filed by the patient or the health care provider filling out apaper form. The completed paper form was then mailed to the insurancecompany. At the insurance company, the paper claim form went through aseries of administrative steps, all the time remaining as a hard copypaper object. When a decision was made, the decision was written up andarchived with the claim form; a hard copy was also sent to the patientand/or provider along with the payment.

(2) The first significant advancement resulted from the introduction ofthe mainframe computer. This allowed for electronic processing within agiven insurance company, i.e., once the claim was on the computer insidethe company, the paper form could be dispensed with. Computerization isa highly effective way of reducing administrative overhead in claimsprocessing.

Thus, mainframe computers were purchased and installed internally at theinsurance companies. Since these computers were intended for internaluse only, each company thought only of its own needs and had its claimsmanagement software customized. While the claims management software fora number of insurance companies would be written in the same high-levelprogramming language, e.g., COBOL, the similarity between softwareprograms often ended there. There were many virtues to these earlysystems, primarily with respect to decreased administrative costs, but amajor drawback was that the data for each “paper” claim had to beentered into the computer to form an electronic claim. This necessitatedthe manual transcription of exactly the same information that had beenhandwritten into the original paper claim before it was sent to theinsurance company.

(3) The next advancement was the electronic filing of claim forms. Thiswas made possible by the introduction of the personal computer and modeminto the provider's office. The main purpose of this stage was toeliminate the manual re-entry of information into the insurance companymainframe.

The basic idea was to have the providers fill out an electronic claimform, instead of a paper claim form. This electronic form, which wouldbe stored in the memory of their PCs, would then be transmitted, as acomputer file, to the insurance company. It could then be integrateddirectly into the electronic claims processing system without the manualre-entry of data. Thus, the technology existed to produce a system thatcomputerized the overall filing and processing of the insurance claimfrom the point of entry, the provider's office, to the final report ofthe claims adjuster.

Although the idea was straightforward, implementation was not. Two basicproblems had to be overcome in order to create a viable system. First,the information contained in the electronic claim form had to beintegrated into the claims processing software at the insurance company.Second, a majority of providers have to be able to interface with amajority of insurance companies, i.e., insurance company mainframecomputers. However, because of the way computers had entered theinsurance industry originally (stage #2), there was no industry-widestandard, i.e., the legacy mainframe computers of the differentinsurance companies were incompatible. This was true both with respectto the type of software used and with respect to the information thateach company required on its claim form.

One attempt to deal with these problems was the creation, by aconsortium of insurance companies, of the National ElectronicInformation Corporation (NEIC). NEIC's basic function is that of aclearinghouse. It interfaces between the insurance companies and theservice providers. It also establishes rigid standards that must be metin order to transmit an electronic claim form to an insurance company.In practice, the service provider sends an electronic claim to a vendor,who performs a service such as screening of the form. The vendor thentransmits the form to NEIC, which then re-transmits it to the patient'sinsurance company. Since it is a computer file, the information in theelectronic claim form can then be entered directly into the company'smainframe claims processing system, without the manual re-entry of data,and then processed.

Thus, a coherent system was created that allows for the electronicfiling, transmission, and processing of insurance claims. This system isemployed by thousands of providers and hundreds of insurance companies.

NEIC was designed to act as a clearinghouse for claims that are 100%text and that conform to very restrictive formats. For claims that meetthese conditions it functions well, resulting in substantial savings onadministrative costs for the insurance companies. It has been estimatedthat going to this third stage system results in savings of as much as60% in claims processing costs.

But there are many claims that do not meet these conditions. These wouldinclude claims that require additional text information that doesn't fitinto the prescribed format and/or claims that require non-textinformation. In general, these are called “claims with attachments.”“Attachments” are any additional information that must be sent with the“standard text claim form.” This could include: pictures, graphs,additional text not allowed on the standard claim form, soundrecordings, etc.

An example of such a claim would be the PAC (Prior Approval Claim),which may be alternately denoted as a “Pretreatment Claim”. These areclaims that are sent to the insurance carrier before a procedure isperformed. For example, pretreatment claims are often required by dentalinsurance companies on any procedure over a specified amount, e.g.,$200. The aspect of this type of claim which renders it incompatiblewith the present electronic claim processing system is that theinsurance companies require that additional medical evidence beincluded, i.e., attached to, the text part of the claim form. In anexemplary case, the additional medical evidence is an x-ray.

The goal of the insurance company is to review the claim, i.e., both thetext form and attachment, and to do so in a cost effective manner. Thenatural next stage in the development of claims processing systems is toattempt to computerized this process.

Scanners are now available that can digitize a dental x-ray, i.e.,convert it into a computer file that can be viewed on a monitor. Buttransforming the medical evidence into digital form is not enough tofacilitate electronic processing of claims with attachments. One mustalso take into consideration the existing claims processinginfrastructure, i.e., the legacy infrastructure.

The difficulty with trying to include a digitized x-ray for processingwith an electronic claim form, within the current infrastructure, ismultifaceted. First, NEIC does not at the present time allow this typeof information to be transmitted through NEIC to the insurancecompanies. Second, with the current system, the claims adjusters accessclaims information through terminals connected to mainframes. But thereis the inherent problem of displaying images on mainframe computers.This is especially true of mainframe computers running software writtenin business programming languages such as COBOL. It might be thoughtthat a solution to this problem would be to replace the terminal with aPC. Although many personal computers provide the graphics support neededto display the digitized x-ray, there are significant problems ininterfacing a PC with a mainframe computer. For example, in order tointerface with the mainframe computer, PCs often run terminal emulationsoftware which permits the PC to act like a dedicated, dumb terminalattached to the mainframe computer. Terminal emulation software isnotoriously lacking in graphics capability. And finally, getting adigitized x-ray from one provider to one insurance company is not allthat is needed. Rather, what is really needed is an industry-wide systemwhereby a provider can interact with any insurance company. This resultsin a massive interfacing problem since there are multitudes of insurancecompanies using different legacy hardware systems and company uniquesoftware.

Each time a way has been found to more fully utilize computers in claimsprocessing systems, the administrative costs associated with claimsprocessing have gone down. However, in the area of “claims withattachments,” no coherent industry-wide system exists that allows forthe integrated filing, transmitting and processing of these claimselectronically, i.e., via computers. Thus, when attachments arerequired, providers are forced to submit hard copy claim applications,while insurance companies labor under an administrative system that is ahybrid between a manual and an electronic system, i.e., a hybrid betweenstage #1 and stage #2. This hybrid system, which is described in greaterdetail below, is labor intensive, prone to problems, and slow. Forproviders, insurance companies, and patients, this is a time-consuming,costly and irritating process.

In short, there is at least one type of insurance claim that has not,until now, been able to avail itself of the third stage ofcomputerization, as described above. In fact, there are evendifficulties with the second stage. This group includes any claim whose“standard text form” must be accompanied by additional information thatdoes not fit into this standard format, e.g., x-rays, EKGs, additionaltext information such as Operating Room Reports, etc. In general, theseare referred to as “attachments.” One primary example of this would bePrior Approvals for dental procedures. Prior Approval Claim (PAC)applications are those claims that are submitted for the purpose ofreceiving a predetermination of benefits from the insurance company fora procedure that hasn't as yet been performed.

In the area of Prior Approval Claims, the goals of the insurancecompanies are to validate the necessity of the procedure and todetermine whether the patient's insurance policy obligates the insurancecompany to pay for such a procedure. This requires that the insurancecompany itself review the medical evidence. For an insurance company'sin-house dentist, for example, to make this appraisal, the dentist isrequired to review both the “text form” and the accompanying x-ray ofthe patient. However, the presence of a film x-ray means that electronicclaims methods cannot be implemented. The savings associated withelectronic claim processing is not available with respect to PriorApproval Claim forms.

Nationwide, there are approximately 200,000 dental PACs filed per week.Roughly, for every PAC application there will be eventually a FinalPayment Claim (FPC) submitted when the medical procedure is completed.It is estimated that the overall administrative cost is $25 per PAC formand $10 for the Final Payment Claim. It is also estimated that if acoherent electronic system could be implemented, it would reduce theseadministrative costs to $15 per PAC and $5 per Final Payment Claim. Thesavings could amount to as much as $3,000,000 per week collectively forthe health care industry for dental PACs and FPCs alone.

An example of a hybrid system of claim processing currently in use willnow be described with reference to FIGS. 1, 2A and 2B.

Referring first to FIG. 1, the U.S. Postal Service, denoted as 100,connects the service provider's office 200 with the insurance company300. It will be appreciated that, since PAC form handling is entirelymanual at location 200, the service provider's office is depicted aslacking computer equipment. In contrast, the insurance company typicallyhas at least one mainframe computer 350 to which terminals 351, 352 onthe respective reviewing dentist's desk 360 and claims adjuster's desk370 are connected. It should also be noted that the mail room 320 ischarged with a variety of tasks associated with the incoming andoutgoing correspondence, as discussed in greater detail below.

As will be appreciated from FIG. 1, a paper PAC form is filled out bythe patient and/or the provider and, along with the substantiatingx-ray, is mailed to the patient's insurance company. Upon entering themail room of the insurance company, the PAC form is assigned a documentidentification number (DIN) and the data from the PAC form is thenentered into the company's mainframe computer. This same DIN is affixedto the x-ray. The x-ray is then manually delivered to the reviewingdentist.

By using the DIN on the x-ray, the reviewing dentist downloads, from themainframe computer, the textual part of the patient's PAC application.The dentist makes a decision, records it in the memory of the mainframecomputer, and has a hard copy of the Predetermination form posted backto the provider. Once the procedure has been completed, the provider'soffice completes the Predetermination form, or fills out a separateFinal Payment Claim (FPC) form. This is then posted to the insurancecompany. A chronological, detailed, step-by-step description of thehybrid system will now be provided with reference to FIGS. 1, 2A and 2B.

During step S1, the dentist decides that a costly procedure is necessaryfor a patient whose insurance carrier requires prior approval for suchtreatment. During step S2, the dentist provides the patient with hisdiagnosis and gives the patient an estimate for performing therecommended procedure. The dentist then asks the patient to contact hisinsurance carrier, or plan administrator at work, to obtain thenecessary PAC form. During step S3, the patient completes that portionof the PAC form that pertains to him, signs the form, and sends it tohis provider.

After the PAC form arrives at the provider's office at step S4, one ofthe office personnel retrieves the patient's file and the PAC form atstep S5, extracts the patient's x-ray, either the original, a copy ofthe original, or a second, previously taken x-ray, during step S6, andthe PAC form is filled out entirely by hand, i.e., the information aboutthe provider has to be entered every time a new PAC form is received,during step S7. Copies of the completed form are made and are placed inthe patient's file during step S8. The envelope containing the PAC formis addressed to the appropriate insurance company at step S9. The formand the x-rays are placed in the envelope during step S10. An entry ismade in both the patient's computer file (if the provider's office isequipped with one) and his hard copy file indicating that the PAC formhas been sent during step S11 and, finally, during step S12, theenvelope is mailed. See task T1 in FIG. 1.

The envelope meanders through the U.S. Postal Service 100 for severaldays at step S13 until the envelope finally arrives at the mail room 320of the insurance company 300 at step S14. In the mail room, the envelopeis opened (step S15), the data from the PAC form is entered into theinsurance company's mainframe computer 350 and is given a DocumentIdentification Number (DIN) that identifies the patient and the currentclaim application (step S16). See task T2 in FIG. 1. During step S17,the x-ray is labeled with the same DIN. It will be appreciated that theDIN on the x-ray and in the document now on the mainframe computer mustbe identical. It will also be appreciated that for some insurancecompanies, this manual processing is contracted to an outside agency,which would require several more steps, which steps will not bedescribed further.

During step S18, the x-ray is manually forwarded to the reviewingdentist's area. See task T3 in FIG. 1. During step S19, the PAC form istransferred to a directory and waits to be read by a reviewing dentist.

During step S20, a group of x-rays arrives from the mail room at thereviewing dentist's area. A film x-ray is pulled out of the waiting pileby the dentist during step S21 and the reviewing dentist then accessesthe “PAC form” directory during step S22 by, for example, reading theDIN from the x-ray and typing the DIN into the computer. The electronicPAC form corresponding to this x-ray is located in memory and downloadedto the reviewing dentist's monitor during step S23.

The procedure requested is read off the terminal monitor and the filmx-ray is reviewed during step S24 and a determination is made duringstep S25. It will be appreciated that a determination refers to eitheran approval or a denial of the request. Assuming that the procedure isapproved, a statement (or explanation) of benefits (EOB) is alsogenerated. For the purposes of this discussion, it will be assumed thatthe procedure is approved; a denial would necessitate a parallel butalternative set of processing steps, which steps will not be furtherdescribed. During step S26, the insurance company's Predeterminationform is filled out either electronically or by hand. For an electronicPredetermination form, the form is saved to the memory of the insurancecompany's mainframe computer during step S27. The x-ray is returned tothe mail room during step S28. See task T4 in FIG. 1.

Following approval, a paper copy of the Predetermination form is madeduring step S29. See task T5 in FIG. 1. An envelope is then addressed tothe referring dentist and the Predetermination form is placed in theenvelope during step S30. During step S31, the corresponding x-ray ismatched with the Predetermination form and, during step S32, thecorresponding x-rays are placed in the envelope. The envelope then goesback into the U.S. Postal System 100 during step S33. See task T6 inFIG. 1.

Some days later, the envelope finally arrives at the dentist's office200 and is opened during step S34. The results are noted in both thepatient's paper file and computer file during step S35, the x-rays arereturned to the patient's paper file at step S36, and the patient isnotified of the approval and a date is set for performing the approvedtreatment during step S37.

The treatment is completed during step S38 and the Final Payment Claim(FPC) form is filled out during step S39. It will be appreciated thatthe Final Payment Claim form, for many insurance companies, is merely asubsection of the Predetermination form generated in step S29 (See thepaper denoted P* in FIG. 1.); alternatively, the Final Payment Claimform could be yet another form supplied by the insurance company.

The Final Payment Claim form is then sent back to the insurance companywith a copy of the signed Predetermination form during step S40. Seetask T7 in FIG. 1. The Final Payment Claim form enters the mail room asa paper form and the final processing begins during step S41. It will beappreciated that the processing of the Final Claim Form typicallyrequires making several entries in the information stored on themainframe computer 350 and may require the preparation of one or moreforms needed to authorize payment of the final claim. However, since anattachment is not normally associated with the Final Claim Form,additional discussion regarding disposition of the Final Claim Formwithin the insurance company will not be provided.

Thus, the hybrid system under discussion is one that starts in theprovider's office when a patient is told that a PAC form is needed andcontinues until the procedure has been completed and a Final PaymentClaim form has been submitted to the insurance company for payment. Itwill be appreciated that a myriad of problems and inefficiencies arisedue to claim processing in accordance with the hybrid system. Theprincipal problems are as follows:

-   -   1. All information needed to complete the PAC form has to be        entered by hand. Moreover, all of the information on the PAC        form is also manually transcribed in order to transfer the        information from paper to the insurance company's mainframe        computer. Both of these manual data entry process steps are time        consuming, very costly, and prone to human error;    -   2. The x-ray film and the text form are put together and then        separated several times during the overall claim processing;    -   3. The hybrid system requires that a hard copy of the x-ray be        sent to the insurance company. Generally, this x-ray is returned        to the provider. Moreover, the requirement that the dentist        provide the x-ray typically means that a duplicate x-ray has to        be made by the dentist, which increases the dentist's cost for        the service. Oftentimes, the duplicate x-ray is of poor quality        and cannot be read;    -   4. Because prior approval claim forms cannot be processed        electronically, and because PAC forms make up half of all the        claims that approximately 20,000 oral surgeons, periodontists,        and orthodontists make each year, these 20,000 providers have no        compelling reason to initiate electronic claims for Final        Payment Claims;    -   5. The document identification number is affixed to the x-ray        and the electronic text in two different processes, one physical        and the other electronic. This leads to errors;    -   6. After the procedure has been completed, almost identical        information may again have to be entered by hand in order to        prepare the Final Payment Claim form;    -   7. While direct digital x-ray equipment is available, it is        difficult to integrate a digital x-ray into the current hybrid        claims processing system, i.e., these computerized images would        first have to be transferred to film, which would, of course,        negate the major advantage for using direct digital x-rays;    -   8. Some insurance companies would like to require that x-rays        accompany all dental claims; they are prevented from doing so        because of the high administrative overhead associated with        handling hardcopy claims;    -   9. The patient has to obtain the PAC form from the insurance        company or his employer. In either case, this causes the patient        time, is an irritant, and imposes unnecessary delays on the        delivery of medical care to the insured;    -   10. With the hybrid system, no prescreening of the PAC form for        errors is performed before the PAC form goes to the insurance        company; and    -   11. Provider information, i.e., the dentist's information, often        has to be entered separately on each new PAC form that is        submitted.

In summary, the current method for handling PAC applications is a hybridsystem somewhere between a Stage 1, a totally paper-based manualprocessing system, and a Stage 2 internally computerized insurancecompany processing system. It is part electronic and part hard copy.Also, each form must be handled twice, once as a hard copy and once asan electronic copy. This is the source of a great many of the abovedescribed problems. Moreover, the current hybrid method is costly. Theprocess starting at the provider's office, continuing through theinsurance company and finally to the return of the Predetermination formto the provider has been estimated to cost $25. Furthermore, the wholeprocess is filled with potential for error, frustration, wasted time andmoney.

The workflow for the filing and processing of a PAC form was describedabove with respect to the dental health insurance which was used, by wayof example, to illustrate the circuitous process involved when a hardcopy attachment is present. Other types of claims, or attachments, ordifferent insurance companies might require slightly different steps.For example, instead of returning an attachment, as describe above, theattachment might need to be microfilmed and archived, or some of theinformation contained in the attachment itself might need to be enteredinto the mainframe. Regardless of these differences, there aresimilarities in the problems that arise in processing such claims.

The present invention was motivated by the desire to overcome theproblems associated with the above-described hybrid system forprocessing “forms with attachments.” The intent was to create a coherentsystem that allows for the electronic filing, transmission, andprocessing of these forms, e.g., claims. That is, a system that wouldcreate a Stage #3 level of computerization for “forms with attachments.”More specifically, the present invention was motivated by the desire toeliminate, to the maximum extent possible, all processing stepsdescribed above which are in any way connected with the presence of ahard copy attachment.

SUMMARY OF THE INVENTION

One purpose of the present invention is to create a coherent system thatallows for the electronic filing, transmission, and processing of“insurance claims with attachments,” and to thereby overcome the manydeficiencies of the hybrid system claims processing methodologydescribed above.

Thus, one object according to the present invention is to provide a PACform processing system which minimizes the necessity of manual dataentry. According to one aspect of the present invention, only about 40%of the information needed to complete the PAC form has to be entered byhand. According to another aspect of the present invention, the amountof information that has to be manually re-entered by an operator isessentially zero.

Another object according to the present invention is to provide a PACapplication processing system which eliminates handling errors resultingin a mismatch between, for example, a PAC form and an associated patientx-ray. According to another aspect of the invention, mismatch errors arevirtually eliminated since the electronic x-ray and the associated textare never separated; field data included in, for example, the PAC formis copied and transferred between the server and the mainframe computersystems inside the insurance company. According to yet another aspect ofthe invention, mismatch errors are virtually eliminated since no hardcopy of the x-ray is ever sent to the insurance carrier.

Still another object according to the present invention is to provide aPAC application processing system which increases the number of serviceproviders employing electronic claims systems to thereby reduce theoverall claims processing costs. Since a PAC form can now be handledelectronically in accordance with the present invention, electronicfinal payment claims become viable for approximately 20,000 additionaldentists.

A still further object according to the present invention is to providea PAC application processing system in which Document IdentificationNumbers, or some other method of uniquely specifying the PAC, aresimultaneously associated with both the text and the x-ray by a singlecomputer entry.

Yet another object according to the present invention is to provide aPAC application processing system which operates at lower cost. Costefficiencies are readily achieved according to the present invention byeliminating the need to send a physical x-ray with the claim.

Another object according to the present invention is to provide a costeffective claim processing system wherein little or no information oneither the PAC form or the Predetermination form has to be manuallyre-entered.

Still another object according to the present invention is to provide asystem for packaging textual data with an associated digitized x-ray fortransmission to an insurance company. It will be appreciated that directdigital images are easy to integrate into the system because such imagesare already in the form of a computer file.

Another object according to the present invention is to provide atotally digital PAC application processing system which can accommodateboth text and digitized x-rays at low cost, thereby allowing insurancecompanies to require x-rays with all claims because such requirementswill not significantly increase the processing cost associated withnon-x-ray documented claims.

An additional object according to the present invention is to provide atotally digital PAC application processing system in which acustomizable claim form, i.e., the PAC form, which addresses the needsof all insurance carriers is stored in the memory of the computer inevery service provider's office. This, in combination with anon-clearinghouse communications channel and having AIC system softwareat all of the insurance carriers, then eliminates the need for imposingindustry-wide standards, such as ANSi ASC X12, for claim-relatedelectronic transactions. The present invention allows each individualinsurance company to get the information that it requires and to getthat information in what ever format that insurance company prefers.Moreover, the ability to transmit the customizable claim form andintegrated attachment to an insurance carrier via a non-clearing housecommunications channel advantageously permits the transmission of othertypes of claims, including worker's compensation claims, to theinsurance carrier. In addition, it will eliminate the irritant of thepatient or provider having to obtain a PAC form from a particularinsurance company.

Another object according to the present invention is to provide atotally digital PAC application processing system in which prescreeningof information entered into a PAC form, which is stored in the memory ofthe computer in the service provider's office, is easily performed.

Yet another object according to the present invention is to provide atotally digital PAC application processing system in which providerinformation is automatically entered into each PAC form.

These and other objects, features and advantages of the invention aredisclosed in or will be apparent from the following description ofpreferred embodiments.

BRIEF DESCRIPTION OF THE DRAWINGS

The preferred embodiments are described with reference to the drawingsin which like elements are denoted by like or similar numbers and inwhich:

FIG. 1 is a combination high level block diagram and flow diagram whichis useful in understanding the operation and attendant problems of thecurrent hybrid system for Prior Approval Claim form processing;

FIGS. 2A and 2B collectively form a flow chart which illustrates ingreater detail the steps needed to implement the hybrid system of FIG.1;

FIGS. 3A-3C are a combination high level block diagrams and flowdiagrams which are useful in understanding the operation and system ofPrior Approval Claim form processing according to various embodiments ofthe present invention;

FIG. 4 is a detailed flow chart of the operational steps needed tooperate the systems illustrated in FIGS. 3A-3C;

FIGS. 5A and 5B illustrate alternative embodiments of the attachmentintegrated claim application according to two of the preferredembodiments of the present invention; and

FIGS. 6A and 6B illustrate clearinghouse and non-clearinghouse networks,respectively, connecting service providers and insurance companies.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention is a system and corresponding method implementedby software loaded onto the system for processing textual messages whichare integrated with one or more attachments. Heretofore, suchattachments could not be readily and/or usefully incorporated with thetextual message. Hereinafter, the term Attachment Integrated Claim (AIC)Application will be used to denote a claim application including a textportion and a digital attachment portion. An exemplary embodiment of thepresent invention combines a patient's digitized x-rays with anelectronic insurance claim form to create an electronic Prior ApprovalClaim (PAC) Application. Another preferred embodiment of the presentinvention is an industry-wide system for the electronic filing andprocessing of these PAC Applications.

It should be noted that the term “digital attachment” as usedhereinafter is not limited to a digitized image or x-ray. The term“digital attachment” is understood to embrace x-rays, CTs, MRIs, EKG orEEG recordings, i.e., strip charts, digitized video signals such asMoving Picture Experts Group (MPEG) compressed video signals,transcriptions of Operating Room Notes, estimates for repairs to a houseor car, Explanation of Benefits (EOBs), additional ASCII text, and thelike. Moreover, all particulars regarding a specific “attachment,” suchas medical specialty, acquiring modality, the patient's problem, etc.,are to be ignored, since such details have absolutely no bearing on thevarious embodiments of the present invention. The only requirementsregarding digital attachments are that the information must be somethingthat can be digitized, i.e., put into the form of a computer file, andthat once in this form, it can be “read, reviewed or interpreted” by theperson or organization receiving it.

The preferred embodiments according to the present invention will bedescribed with reference to FIGS. 3A-3C and FIG. 4. It should bementioned that the descriptions that follow describe the embodiments ofthe invention as they are used in connection with dental insuranceforms. However, the present invention is not limited to systems for theprocessing of dental insurance claims. Rather, the present inventionencompasses the preparation, transmission and processing of datapackages including a plurality of data fields wherein at least one ofthe data fields is a digital attachment, e.g., a digital or graphicimage. For example, casualty insurance claims with supportingdocumentation, i.e., pictures taken with a digital camera, are withinthe scope of the present invention.

Before presenting a detailed description of preferred embodimentsaccording to the present invention, a brief overview of the operatingmethod steps associated with formation, transmission and processing ofthe PAC Application will now be presented. In an exemplary andnon-limiting case, the essential steps of the operating method include afirst subroutine for completing and transmitting needed information to adesignated insurance company. This subroutine includes steps for:

-   -   (1) Retrieving an appropriate electronic PAC form from storage        in the computer's memory and displaying the PAC form on the        computer screen;    -   (2) Filling out of PAC form on the computer screen;    -   (3) Digitizing, e.g., scanning, the patient's x-ray;    -   (4) Combining the digitized x-ray and the electronic PAC form        into the patient's PAC application; and    -   (5) Transmitting the patient's PAC application to the designated        insurance company.    -   After the PAC application is received by the insurance company,        the insurance company performs another subroutine, which        includes steps for:    -   (6) Reviewing the PAC application;    -   (7) Generating an electronic Predetermination form when the        application has been reviewed; and    -   (8) Transmitting the electronic Predetermination form back to        the insured's Service Provider.    -   When the electronic Predetermination form from the insurance        company is received by the service provider, an additional        subroutine is performed by the service provider. This subroutine        advantageously includes steps for:    -   (9) Reading the electronic Predetermination form;    -   (10) When the approved procedure has been performed, adding        completion data to the electronic Predetermination form; and    -   (11) Transmitting the annotated electronic Predetermination form        back to the Insurance Company.

When the annotated electronic Predetermination form is received from theservice provider, the insurance company performs a final subroutine,which includes steps for:

-   -   (12) Reviewing the annotated information; and    -   (13) Issuing the final payment to the service provider.

Embodiment of FIG. 3A

For the embodiment as shown in FIG. 3A, the overall system according tothe present invention includes the computer components 200 located inthe health care provider's office and the computer components 300located on the premises of the insurance company. Infrastructure 400,which advantageously may be an existing on-line service company, ispreferably used in one embodiment of the present invention to facilitatecommunication between the components 200 in the service provider'soffice and the components 300 at the insurance company. Preferably,components 500, which are located at a value-added service company,permit services ordered by the service provider, patient, or insurancecompany to be performed. It should be noted that the components 500 mayduplicate a subset of the components 300 found at the insurance companyand, for that reason, description of the components 300 alone will beprovided below.

As shown in FIG. 3A, the components 200 include a personal computer 210including a screen 212, a keyboard 214 and a modem 216, connected to ascanner 220, a printer 230 and an archiving device 240, e.g., a largememory for storage of digital information. Device 240 advantageously maybe a writeable compact disc read only memory (CD-ROM), i.e., a so-calledwrite once-read many (WORM) device, a hard disk drive, a tape back updevice or a removable hard disk device. It should be recognized that thecomputer 210 advantageously can be a computer system including a centralprocessing unit, a graphic display processor, the graphic display device212, and several memories including both solid state memories and a harddisk drive. It should also be noted that the archive device 240 and oneof the memories associated with computer 210 may be the same memorydevice.

Components 300 located at the insurance company include the previouslydescribed mainframe or legacy computer 350 and terminals 351, 352. Inaddition, a buffer computer 310, which may be a network server, includesa modem 316 and is connected to a printer 330 and a storage device 340.The printer 320 may provide copies of documents directly to the mailroom320. Preferably, the computer 310 is connected to personal computers orwork station terminals 311, 312 via a local area network (LAN) 313.

The method for operating the system according to the embodiment of thepresent invention as depicted in FIG. 3A will now be described indetail.

The method starts at step S101 with the service provider's diagnosisthat a costly procedure is necessary. It is then determined that thepatient needs prior approval from his insurance company. During stepS102, the patient is provided with an explanation of the procedure and acost estimate for that procedure. The service provider and the patientthen prepare the needed PAC Application.

During step S103, a member of the service provider's office staffaccesses the Attachment Integrated Claims (AIC) software stored innon-volatile memory on the service provider's computer system 210, whichsoftware advantageously is Graphic User Interface (GUI) software.Preferably, this AIC software is written in C++, Visual Basic, JAVA orsome other appropriate graphical programming language.

It will be appreciated that commercial software packages, such as LOTUSNOTES™, have been designed with the capability of addressingcombinations of text and graphics files. However, the purpose of thesepackages is to create an “environment” or “platform” in which specificapplications can be developed. In contrast, the preferred embodimentsaccording to the present invention are directed at providing integratedtext and graphics files within a coherent system and methodology foraddressing the specific needs of the work flow, preferably of aparticular industry. That is, it is a particular application. It ispossible, but not necessary, that the software needed to implement thepreferred embodiments of the present invention can be developed withinthe frame work of the environment created by something such as LOTUSNOTES™.

Contained within the AIC software are PAC forms for insurance companiesusing the AIC system. When one of these is opened it acts as a templateupon which a new computer file will be based. This computer file willultimately contain the patient's PAC Application.

It will be appreciated that the PAC form when displayed on thecomputer's screen 212 contains boxes, such as those depicted in FIGS. 5Aand 5B, in which alpha-numeric characters can be entered so that, whenthe characters are entered in these boxes they are entered so as to filla “field,” a delimited alpha-numeric character string. Being a “field,”the information denoted by the characters can be transferred to and usedin completing other fields in related documents. Also, the informationitself, or lack thereof, can be used as a logic control device, e.g.,used to remind the preparer that critical information has not beenentered.

In an exemplary case, the PAC forms of many insurance companies havebeen encoded and stored in memory on the service provider's computersystem 210. This can be advantageously done in the following way. ThePAC forms for all the insurance companies using the AIC System aregathered. Then a union of all the information requested in these PACforms is made. A field is created for each element of informationrequested. For example, Field #1 contains the patient's first name,Field #2 contains the patient's last name, and so on. This is done untilthe “information fields” of the PAC forms for all of the insurancecompanies are included.

In order to increase the efficiency of the clerical staff at theprovider's office, it is desirable to give them basically the same formto fill out every time, i.e., information is always in the same place onthe form. To do this a template is created. What actually appears on thescreen of the preparer is always the same. What changes is that anygiven insurance company will desire only a particular subset of thetotal number of fields. So if insurance company A is chosen, then fields1, 2, 3, 7, 9, . . . have to be filled in, whereas, if insurance companyB is chosen, then fields 2, 3, 4, 5, 7, 11, . . . have to be filled in.The fields not needed are automatically signified in some way by the AICsoftware, e.g., if insurance company A does not need Field #4 then thatblock on the screen is gray and can't be typed into (i.e., is “writeprotected”). Thus a “customized claim form” is provided for everyinsurance company based on a single, universal compilation of fields. Asdescribed below, what allows this method to work is that there is AICsoftware at the insurance company that has been coordinated with the AICsoftware at the providers office.

The AIC Software GUI asks for the name of the insurance company, whichcan be typed in or selected from a directory. Once the insurance companyhas been identified, the fields needed to complete the insurancecompany's PAC form are displayed on the screen 212 of the serviceprovider's computer system 210. The AIC software advantageously canautomatically fill in all the parts of the form that are specific to theservice provider, e.g., name, address, Provider Identification Number(PIN), etc. It is estimated that this alone eliminates 20% of the workneeded to fill out the PAC form. An electronic signature couldadvantageously be added at this time for the service provider or couldbe added as part of the final review and approval before the completedPAC application is transmitted.

Needed patient information is then entered into the PAC form on thecomputer screen 212, preferably while the patient is still in theoffice, and a provider Document Identification Number (PDIN) can be usedto label the form, if so desired. This is now a computer file identifiedas referring to the patient. It should be noted that some form ofsignature can be provided in the appropriate field. As an example, aspecial electronic pad and pen can be used such that when the patientsigns on the pad his signature is affixed to the electronic PAC form.

During step S104, the patient's x-ray is digitized. In an exemplarycase, there is a scanner 220, i.e., digitizer, connected to the serviceprovider's computer system running the AIC software. The patient's x-rayis scanned and converted into a series of ordered numbers (i.e., a bitmap of the x-ray image) and stored. It should be noted that these storedseries of numbers can be reconstructed by the computer system to displaythe x-ray on a computer monitor, i.e., the bit map can be used toreconstruct a raster image of the x-ray for display.

It will be appreciated that the AIC software advantageously can bewritten to minimize the time needed to scan the x-ray. In an exemplarycase, the operator can specify the type of x-ray or x-rays that arebeing scanned. This is done so that blank areas are not being digitizedand added to the patient's file. It will be noted that this will alsosave on transmission time to the insurance company. Further, as will bereadily appreciated by those skilled in the art, the text and image datacomprising the file can be encoded and compressed in any manner wellknown in the art in order to minimize data storage and transmittingclaimed requirements. In addition, security measures can be taken sothat only authorized persons can access the claims.

It should also be mentioned that steps S103 and S104 need not beperformed in any particular order. In an exemplary case, the patient'sx-ray may be digitized before the PAC form is called up on the computerscreen 212 and completed.

During step S105, the PAC application is formed from the electronic PACform and the digitized patient's x-ray. It should be noted that thepresent invention is not limited to a particular format for the PACapplication. For example, the format of the PAC applicationadvantageously may consist of a text file and an associated digitizedimage file. It should be noted that in this case the text and imagefiles will be transmitted seriatim. For that reason, the text file(i.e., the PAC form) and the image file (i.e., the digitized x-ray) mustcross reference one another (i.e., be correlated) so that these filescan be continuously associated with one another after transmission tothe insurance company. If the attachment is simply additional ASCIItext, e.g., Operating Room Notes, then the only step necessary is totransfer the additional ASCII text into the integrated file format. Oncein the integrated file format, all processing is the same as if the filecontained an image attachment.

In an alternative exemplary case, the PAC application advantageously canbe prepared according to the Graphic Interchange Format™ (GIF)specification, which specification is the intellectual property ofCompuServe Incorporated. In order to form the PAC application, thedigitized x-ray is converted to a GIF image file. It will be appreciatedthat the GIF image file advantageously can include one or more blocks oftextual data denoted by a comment extension, as described in Version 89aof the GRAPHICS INTERCHANGE FORMAT documentation published byCompuServe, Inc. It should be noted that since the textual informationcorresponding to the data needed to complete the PAC form is included inthe GIF image file comments, the possibility of file separation andconsequent mishandling or mismatching of the separate components of thePAC application is virtually eliminated. Alternatively, the TIFFstandard format advantageously can also be used to co-join field anddigital image data.

It will also be appreciated that the concept of embedding comments intothe GIF or TIFF image file format is a standard practice employed bythose of ordinary skill in the art of graphic image preparation, e.g.,by photographers and digital artists who wish to identify their works.However, it should also be noted that the use of a comment block storingdata fields used in reconstructing a completed form, e.g., a completedPAC form, has never before been described or suggested. Furthermore,since the technique described above is a novel solution toelectronically forwarding an insurance claim form and an associatedattachment as one, the use of the comment block to store the PAC formfield data is likewise a unique and novel aspect according to thepresent invention.

In yet another alternative exemplary case, the digitized x-ray isautomatically added (inserted) to the electronic form by the serviceprovider's AIC software and forms a single computer file, as depicted inFIG. 5B. It should be noted that the non-text portion of the PACapplication is labeled with the same provider Document IdentificationNumber (DIN) as used on the text portion, i.e., the electronic PAC form.These two objects together now form the patient record, i.e., thepatient's PAC application. The PAC application is now ready to be sentto the insurance company.

During step S106, the service provider's office staff then transmits thecompleted PAC application to the insurance company. For example, whenthe transmission icon of the GUI AIC software running on the serviceprovider's computer system 210 is activated (e.g., “clicked” on), thefollowing substeps are automatically executed:

-   -   (a) A check is first performed to ensure that the PAC        application has been completely filled out. In the event that        problems and/or errors are noted by the AIC software, the system        user is notified of the error by an appropriate annunciator,        e.g., the suspect area can be highlighted and a message        concerning the problem and/or error could be generated and        displayed on the monitor;    -   (b) A hard copy of the PAC application is printed out, if        desired, by the service provider. The hard copy may        advantageously be placed in the patient's permanent file;    -   (c) Moreover, and more importantly, the completed PAC        application is archived in the service provider's computer        system 210, 240. It will be appreciated that this archive copy        can be accessed in several ways such as by patient name, social        security number, document identification number, etc. That is,        it can be accessed using any of the information that has been        entered into the PAC form; and    -   (d) The service provider's computer system establishes a        connection with the on-line service 400 and transmits the        patient's PAC application to the insurance companies e-mail        address. See task T1 of FIG. 3A. It will be appreciated that the        e-mail addresses of all the insurance companies have been stored        in the AIC software residing in the memory of computer system        210. Advantageously, the PAC application can be transmitted        immediately or can be scheduled for transmission at a convenient        time, i.e., can be transmitted after all of the PAC applications        and other forms have been prepared for the day. Preferably, the        AIC software on the service provider's computer system 210 keeps        a record of when the PAC application was sent. In addition, the        AIC software maintains and uses the proper protocols so that        when the PAC application reaches the intended insurance company,        it arrives there with the alpha-numeric portion of computer file        intact, i.e., the information is stored in fields that can be        read by the corresponding AIC software module in the computer        system 310 at the insurance company.

It should be noted that the specific transmission path taken by the PACapplication from the service provider's computer system 210 to thecomputer system 310 maintained by the insurance company is not anessential limitation of the novel system and corresponding operatingmethod according to a preferred embodiment of the present invention. Theonly requirement of a transmission path is that it maintain the digitalintegrity of the PAC application computer file. Thus, the patient's PACapplication can be sent to the insurance company in several ways usingmodems 216 and 316, including via normal phone service, an on-lineservice, or bulk data transmission lines.

In an alternative exemplary case, the completed PAC applications mayeven be transferred to tape and then sent through the U.S. PostalService 100 of FIG. 1 to the insurance company's mailroom 320. Forpurposes of the discussion which follows, only the exemplary case inwhich the PAC application is transmitted via the on-line service 400 isdescribed in any detail.

One of the beneficial aspects of the present invention is provided bythe combination of the customizable claim form on the service provider'scomputer 210 and the use of any non-restrictive communications channel,i.e., the insurance companies are able to freely modify informationrequirements demanded of the service providers. Existing electronicclaims processing systems, such as NEIC, are based on a clearinghouseconcept, as illustrated in FIG. 6A. In a clearing house system, allclaims enter the clearinghouse computer(s), are manipulated, and thenare transmitted to the appropriate insurance company. One consequence ofthe clearinghouse architecture is that it puts a constraint on theinsurance company to use a standardized claim form. The individualinsurance companies have no control of the information content in theform. Moreover, because the claim form is standardized, changes are verydifficult to make, i.e., any change would require all member insurancecompanies to make the change together.

In contrast, placing AIC software packages in the providers' offices andin the insurance company processing centers, where the packages arecoordinated with one another, allows every payer to transmit claim formupdates to every provider. There is no central computer that manipulatesthe claim forms. In the provider's office, the change would be reflectedprimarily in changes to the number of fields needing information and,rarely, in the addition of a new field to be completed by the provider.

As illustrated in FIG. 6B, the interchange between the provider's officeand the insurance company(ies) advantageously can be performed using anonline service or Internet Service Provider (ISP), providing that theservice provider permits 8-bit file interchanges. In that case, theupdate information could be transmitted to the provider when theprovider dials into the online service. Thus, while it is true thattransmission accomplished using e-mail involves an intermediarycomputer, the online service merely provides a mail box and places noconditions on the insurance information contained in the claim itself.

Advantageously, the non-clearinghouse architecture and coordinated AICsoftware package of the embodiment of FIG. 3A facilitates the provisionof the customizable claim form. That is, each insurance company candetermine the content of its own claim form. The packages used by theproviders are instructed regarding the information content, protocols,etc. each insurance company wants its claim to have. It will beappreciated that the package at each insurance company is designed toaccept only those claims that meet the specifications of the respectiveinsurance company. In addition, if an insurance company wants to changethe content of its claim form, it can do so independently of the otherinsurance companies.

Beneficially, the non-clearinghouse architecture of the embodiment ofFIG. 3A reduces costs, allows for the direct digital interchange of datafrom one insurance company to another, and permits many different typesof forms to be run off the same system, e.g. commercial insurance claimsand workers' compensation claims can both be processed in the provider'soffice using the same customizable claim form. This produces a claimsprocessing system which is more robust than anything on the markettoday.

During step S107, the PAC application is pre-processed by thevalue-added service provider 500. For example, the patient's PACapplication can be accessed by the employees of the value-added servicecompany to perform services for either the patient, the serviceprovider, or the insurance company, or any combination thereof. See taskT2 of FIG. 3A. These value-added services could include archiving of thepatient's dental x-rays so that all records for a particular patient arecentrally stored, screening of the entire PAC application for errors,compiling statistics on all PAC applications and, in some instances,even performing the review process for the insurance company.

Next, the insurance company accesses the PAC applications at the on-lineservice during step S108. In an exemplary case, each insurance companyhas an e-mail address specifically for the purpose of receiving PACapplications. An insurance company accesses its e-mail box and finds awaiting list of PAC applications which are subsequently downloaded toGUI-capable computer system 310. In a preferred embodiment as shown inFIG. 3A, the GUI-capable computer system 310 is separate from the claimsmanagement mainframe computer 350 of the insurance company 300.Preferably, the GUI-capable buffer computer system 310 is a personalcomputer (PC) or a PC server which advantageously can be operated inparallel with but separate from the insurance company's mainframecomputer 350.

In an exemplary case, this buffer computer 310 is part of a local areanetwork (LAN) 313, which is connected by high bandwidth cables topersonal computers or other GUI-capable terminals 311, 312 at the desks360 and 370 of the individual reviewing dentists and claims adjusters,respectively. It should be noted that the necessary AIC software hasbeen loaded onto the server 310 and onto the individual personalcomputers 311, 312. Preferably, once the patient's PAC application hasbeen received, the system's AIC software at either the value-addedservice provider 500 or the insurance company's computer 310automatically notifies the referring service provider that the PACapplication has been received for processing, e.g., using a conventionale-mail message.

At step S109, the reviewing dentist calls up the PAC application, in anexemplary case, from the server 310 to a personal computer 311, each ofwhich is running the appropriate AIC software, via the LAN 313. See taskT3 in FIG. 3A. It should be noted that some small insurance companiesmay not even require server-LAN 310, 313 system discussed above, butjust a single PC that will incorporate the functions of the elements310, 311, 312, and 313. In any event, the reviewing dentist calls up apatient's PAC application on his personal computer 311. When thishappens, the system AIC software automatically inserts the insurancecompany's Predetermination Form into this file. The installed AICsoftware advantageously can automatically transfer whatever informationfrom the PAC application to the Predetermination form that is useful incompleting the Predetermination form, e.g., repetitiveinformation/fields. For instance, the service provider's DocumentIdentification Number (PDIN) and the Provider Identification Number(PIN) can be transferred automatically to the Predetermination form. Inaddition, the AIC software can be written to display the information inthe PAC form on the screen 311 in exactly the way that this particularinsurance company wants it displayed.

With the AIC system described above, the use of “fields,” thecustomizable claim form, and the placing of coordinated AIC software atboth the service provider's office and the insurance company, haseliminated the need for standardized forms. The result is that eachinsurance company gets exactly the information it wants and has itdisplayed in exactly the way it wants. Thus, the compromise of astandardized claim form as is required with the present NEIC system isavoided.

In an exemplary case, the reviewing dentist is provided with threemonitors or a large graphics-capable monitor having a multi-page displaymode, on which can be displayed the three pages of the patient file. Itwill be appreciated that this configuration is optimized to facilitaterapid review of the PAC application. The reviewing dentist enters anInsurance Company Document Identification Number (DIN) at this point,which number is affixed to all three pages of the patient's file.

During step S110, the reviewing dentist reviews the PAC application.More specifically, the review process consists of a review of themedical facts or evidence (i.e., the text and x-ray information in thePAC application), as well as a review of the patient's insurance policy.Once the reviewing dentist has made his analysis, he goes to thePredetermination form, i.e., the third page, and enters the requiredinformation to either approve or disapprove the procedure during stepS111. The specific details regarding the information provided by thereviewing dentist will depend on the procedures established at eachindividual insurance company. Either the reviewing dentist or anotherperson, e.g., a claims adjuster, will do the review of the patient'sinsurance policy.

Advantageously, there are several ways to gain access to thisinformation. First, the server 310 can have information on every policyholder loaded into its memory. Second, the benefits reviewer, i.e.,either the reviewing dentist or the claims adjuster, can have anothermonitor 351, 352 on his desk that is connected to the company mainframecomputer 350. Thus, all that the benefits reviewer must do is type inthe patient's insurance ID number and his benefits sheet will appear.The benefits reviewer then reads off the information that must beentered in the Predetermination form and enters the information into theGUI-capable computer system 310/311/312 during step S111. It shouldagain be noted that there is no electronic connection, in the preferredembodiment, between the mainframe computer 350 and the server 310. Thereviewer can, at this time, also enter whatever information is deemednecessary by that particular insurance company into the mainframecomputer 350. See task T4 in FIG. 3A.

At this point, the Predetermination form is ready to be sent to thereferring service provider. When the transmit icon on the computerscreen of the benefit reviewer's GUI-capable computer system isactivated (e.g., by being “clicked” on), the following substeps areautomatically performed:

-   -   (a) First, a check is performed to verify that the        Predetermination form has been completely and properly filled        out. If errors are detected, the AIC software notifies the        operator via an appropriate annunciator;    -   (b) The Predetermination form and the patient's PAC application        are downloaded to the buffer computer 310. See task T5 of FIG.        3A. From this platform, the company accesses the on-line service        400 and transmits the Predetermination form, i.e., just the        information “fields,” to the service provider's e-mail address,        which is stored in the memory of server 310. See task T6 of FIG.        3A. In the AIC software, records are kept as to which PAC        applications have been sent and when and to whom. The proper        protocols are used so that when the application reaches the        service provider, it arrives there as a computer readable file,        i.e., the information is stored in “fields” that can be read by        the AIC software at both the insurance company and the service        provider's office;    -   (c) A hard copy of the Predetermination form and x-ray are        printed, if desired, by the insurance company, see task T7 of        FIG. 3A;    -   (d) The complete patient file is archived in the insurance        company's computer system 310, 340, if desired. See task T8 of        FIG. 3A. Otherwise, just the electronic Predetermination form        and the PAC application are saved; and    -   (e) The entire three page patient file is now cleared from the        reviewing dentist's display 311 and the AIC software prompts the        reviewing dentist as to whether another patient file should be        accessed.

During step S112, the service provider accesses his e-mail address withthe on-line service 400. All Predetermination forms which have beenreceived are automatically delivered to the service provider's computersystem 210 for insertion into the appropriate patient file. The serviceprovider then reviews the Predetermination forms. Upon evaluating thedecision of the reviewing dentist, the service provider can eitherperform the procedure (if approved) or discuss the matter with thepatient's insurance company (if not approved).

During step S113, the approved procedure is performed by the serviceprovider. Once the approved procedure has been completed, the serviceprovider preferably sends in the Final Payment Claim (FPC) form. In anexemplary case, this could be as simple as just filling out anothersection of the Predetermination form and signing it using the electronicsignature pen, as discussed above. It should be noted that in FIG. 3A,this is labeled as P*. Alternatively, if the insurance company sodesires, a separate form just for this purpose can be employed. Thislatter form, which advantageously is stored in the memory of theprovider's computer, must have the Insurance Company's DIN for thisparticular patient's procedure and all other needed informationtransferred to it, which advantageously can all be done by the AICsystem software at step S114. At step S115, the Final Payment Claim formis transmitted back to the insurance company. See task T9 of FIG. 3A. Inan exemplary case, activating the transmit icon on the serviceprovider's computer system 210, e.g., by “clicking” on it, automaticallyresults in the execution of the following substeps:

-   -   (a) A check is performed to see that the form has been        completely and correctly filled out. If an error has occurred,        the AIC software alerts the operator of the detected error;    -   (b) A hard copy of the form is printed out, if desired, by the        service provider;    -   (c) The complete patient's electronic file is archived in the        service provider's computer system 210, 240. It will be noted        again that the patient's electronic file can be accessed by        patient name, social security number, document identification        number, etc.; and    -   (d) The computer system 210 establishes a connection with the        on-line service and transmits the patient's Final Payment Claim        (FPC) form to the insurance company's e-mail address.

As previously discussed, the AIC software on the service provider'scomputer system 210 advantageously may include facilities fortransmitting the Final Payment Claim form to the insurance company at alater time, e.g., for transmitting all of the days PAC application andFPC forms at one time.

It will also be noted, as discussed above, that the AIC softwaremaintains records as to which claim form was sent and when it was sentto the insurance company. In an exemplary case, the e-mail address towhich the Final Payment Claim form is sent is different from the addressused in transmitting the PAC application. Since the Final Payment Claimform does not include a digitized image, i.e., a digitized x-ray, theinsurance company may choose to have the Final Payment Claim formdirected to an e-mail address accessible from the mainframe computer350. If the insurance company's processing protocol requires anindependent review of the PAC application, the Predetermination form andthe Final Payment Claim form before payment can be authorized, thee-mail address will be accessed from, for example, the server 310 andnot the mainframe computer 350, since the mainframe computer 350 isincompatible with the PAC application.

The insurance company then receives the Final Payment Claim forms duringstep S116 when it accesses its Final Payment Claim forms mail box. In anexemplary case, the computer system receiving the Final Payment Claimforms is not the claims management mainframe computer 350 of theinsurance company but, rather, it is a personal computer or server 310that is part of a parallel system having no electronic connection to themainframe computer 350. This buffer computer 310 advantageously can bepart of a LAN 313. The buffer computer 310 is connected by highbandwidth cables to the personal computers or GUI-capable terminals 312located at the claims adjusters' desks. See task T10 of FIG. 3A. Itshould again be noted that the appropriate AIC software modules havebeen loaded onto both the server 310 and the personal computers 312.

The Final Payment Claim form is then reviewed during step S117. Theadjuster reviewing the Final Payment Claim form can, if necessary, callup the PAC application from the memory of the server 310, since theoriginal Insurance Company Document Identification Number for thecorresponding PAC application was transferred to the Predeterminationform and, thus, to the Final Payment Claim form. In addition, theadjuster can, if need be, call up the information on the insurancepolicy of the particular patient. The insurance company can either makethis available in memory on the server 310 or the insurance company canprovide the adjuster with a separate monitor 352 connected to the claimsmanagement mainframe computer 350.

Whatever internal paperwork is necessary to be filled out isautomatically downloaded with the Final Payment Claim form itself by theappropriate AIC software module. Part of this paperwork will preferablybe form(s) which must be completed so as to order a check issued to theservice provider along with an Explanation of Benefits (EOB). Also atstep S118, whatever information is necessary to be entered into themainframe can be done through the use of the terminal 352.

Finally, upon activating the transmit icon on the insurance company'spersonal computer 312, the following substeps are automaticallyexecuted:

-   -   (a) A check is again preformed to see that the form has been        completely and correctly completed and the operator is notified        if an error has occurred;    -   (b) A hard copy of the form is printed out, if desired by the        insurance company;    -   (c) The complete patient file is archived in the insurance        company's computer system, e.g., on the server. It should again        be noted that the patient file can be accessed using the        patient's name, social security number, or an assigned document        identification number, etc.; and    -   (d) A payment draft is issued, in the approved amount, to the        service provider. This can be done through any number of        methods, including printing a hard copy check and forwarding it        through the U.S. postal service, electronic funds transfer, etc.        Each form of payment will be accompanied with the normal        description of the service to which these funds should be        applied, i.e., the EOB (Explanation of Benefits).

Finally, it should again be mentioned that the exemplary preferredembodiment of the AIC system according to the embodiment of the presentinvention as depicted in FIG. 3A is a stand-alone system. Thus, it isindependent of NEIC, mainframe computers 350, and existing claimsmanagement and practice management software. It will be appreciated thatthe stand-alone characteristic of the AIC system at the insurancecompany level enhances the reliability of the insurance company'shardware. In other words, the AIC system and software, which isindependent of the mainframe computer 350, cannot cause mainframe systemcrashes that could interrupt the processing of other types of claims. Ofcourse, alternative preferred embodiments of the present invention whichintegrate the AIC software with the claims management software maynegate this particular advantage.

Embodiment of FIG. 3B

For the embodiment as shown in FIG. 3B, the overall system according tothis embodiment of the present invention includes the computercomponents 200 located in the health care provider's office and thecomputer components 300 located on the premises of the insurancecompany. Infrastructure 400, which advantageously may be an existingon-line service company, is preferably used in the exemplary embodimentof the present invention to facilitate communication between thecomponents 200 in the service provider's office and the components 300at the insurance company. Preferably, components 500, which are locatedat a value-added service company, permit services ordered by the serviceprovider, patient, or insurance company to be performed. It should benoted that the components 500 may duplicate a subset of the components300 found at the insurance company and, for that reason, description ofthe components 300 alone will be provided below.

As shown in FIG. 3B, the components 200 include a personal computer 210including a screen 212, a keyboard 214 and a modem 216, connected to ascanner 220, a printer 230 and an archiving device 240, e.g., a largememory for storage of digital information. Device 240 advantageously maybe a writeable compact disc read only memory (CD-ROM), i.e., a so-calledwrite once-read many (WORM) device, a hard disk drive, a tape back updevice or a removable hard disk device. It should be recognized that thecomputer 210 advantageously can be a computer system including a centralprocessing unit, a graphic display processor, the graphic display device212, and several memories including both solid state memories and a harddisk drive. It should also be noted that the archive device 240 and oneof the memories associated with computer 210 may be the same memorydevice.

Components 300 located at the insurance company include the previouslydescribed mainframe or legacy computer 350 and associated terminals 351,352. In addition, a buffer computer 310, which may be a network server,includes a modem 316 and is connected to a printer 330 and a storagedevice 340. The printer 320 may provide copies of documents directly tothe mailroom 320. Preferably, the computer 310 is connected to personalcomputers or work station terminals 311, 312 via a local area network(LAN) 313. The buffer computer 310 and the mainframe computer 350 areelectronically connected to one another. The details of such aconnection are well known to one of ordinary skill in the art and willnot be described in greater detail.

The method for operating the system according to an embodiment of thepresent invention as depicted in FIG. 3B will now be described indetail.

The method starts at step S101 with the service provider's diagnosisthat a costly procedure is necessary. It is then determined that thepatient needs prior approval from his insurance company. During stepS102, the patient is provided with an explanation of the procedure and acost estimate for that procedure. The service provider and the patientthen prepare the needed PAC Application.

During step S103, a member of the service provider's office staffaccesses the Attachment Integrated Claims (AIC) software stored innon-volatile memory on the service provider's computer system 210, whichsoftware advantageously is Graphic User Interface (GUI) software.Preferably, this AIC software is written in C++, Visual Basic, or someother appropriate graphical programming language.

It will be appreciated that commercial software packages, such as LOTUSNOTES™, have been designed with the capability of addressingcombinations of text and graphics files. However, the purpose of thesepackages is to create an “environment” or “platform” in which specificapplications can be developed. In contrast, the preferred embodimentsaccording to the present invention are directed at providing integratedtext and graphics files within a coherent system and methodology foraddressing the specific needs of the work flow, preferably of aparticular industry. That is, it is a particular application. It ispossible, but not necessary, that the software needed to implement thepreferred embodiments of the present invention can be developed withinthe frame work of the environment created by something such as LOTUSNOTES™. Alternatively, the software needed to implement the preferredembodiments of the present invention can be developed using JAVA™appelets.

Contained within the AIC software are PAC forms for insurance companiesusing the AIC system. When one of these is opened it acts as a templateupon which a new computer file will be based. This computer file willultimately contain the patient's PAC Application.

It will be appreciated that the PAC form when displayed on thecomputer's screen 212 contains boxes, such as those depicted in FIGS. 5Aand 5B, in which alpha-numeric characters can be entered so that, whenthe characters are entered in these boxes they are entered so as to filla “field,” a delimited alpha-numeric character string. Being a “field,”the information denoted by the characters can be transferred to and usedin completing other fields in related documents. Also, the informationitself, or lack thereof, can be used as a logic control device, e.g.,used to remind the preparer that critical information has not beenentered.

In the exemplary case being discussed, the PAC forms of many insurancecompanies have been encoded and stored in memory on the serviceprovider's computer system 210. This can be advantageously done in thefollowing way. The PAC forms for all the insurance companies using theAIC System are gathered. Then a union of all the information requestedin these PAC forms is made. A field is created for each element ofinformation requested. For example, Field #1 contains the patient'sfirst name, Field #2 contains the patient's last name, and so on. Thisis done until the “information fields” of the PAC forms for all of theinsurance companies are included.

In order to increase the efficiency of the clerical staff at theprovider's office, it is desirable to give them basically the same formto fill out every time, i.e., information is always in the same place onthe form. To do this a template is created. What actually appears on thescreen of the preparer is always the same. What changes is that anygiven insurance company will desire only a particular subset of thetotal number of fields. So if insurance company A is chosen, then fields1, 2, 3, 7, 9, . . . have to be filled in, whereas, if insurance companyB is chosen, then fields 2, 3, 4, 5, 7, 11, . . . have to be filled in.The fields not needed are automatically signified in some way by the AICsoftware, e.g., if insurance company A does not need Field #4 then thatblock on the screen is gray and can't be typed into (i.e., is “writeprotected”). Thus a “customized claim form” is provided for everyinsurance company based on a single, universal compilation of fields. Asdescribed below, what allows this method to work is that there is AICsoftware at the insurance company that has been coordinated with the AICsoftware at the providers office.

The AIC Software GUI asks for the name of the insurance company, whichcan be typed in or selected from a directory. Once the insurance companyhas been identified, the fields needed to complete the insurancecompany's PAC form are displayed on the screen 212 of the serviceprovider's computer system 210. The AIC software advantageously canautomatically fill in all the parts of the form that are specific to theservice provider, e.g., name, address, Provider Identification Number(PIN), etc. It is estimated that this alone eliminates 20% of the workneeded to fill out the PAC form. An electronic signature couldadvantageously be added at this time for the service provider or couldbe added as part of the final review and approval before the completedPAC application is transmitted.

Needed patient information is then entered into the PAC form on thecomputer screen 212, preferably while the patient is still in theoffice, and a provider Document Identification Number (PDIN) can be usedto label the form, if so desired. This is now a computer file identifiedas referring to the patient. It should be noted that some form ofsignature can be provided in the appropriate field. As an example, aspecial electronic pad and pen can be used such that when the patientsigns on the pad his signature is affixed to the electronic PAC form.

During step S104, the patient's x-ray is digitized. In an exemplarycase, there is a scanner 220, i.e., digitizer, connected to the serviceprovider's computer system running the AIC software. The patient's x-rayis scanned and converted into a series of ordered numbers (i.e., a bitmap of the x-ray image) and stored. It should be noted that these storedseries of numbers can be reconstructed by the computer system to displaythe x-ray on a computer monitor, i.e., the bit map can be used toreconstruct a raster image of the x-ray for display.

It will be appreciated that the AIC software advantageously can bewritten to minimize the time needed to scan the x-ray. In an exemplarycase, the operator can specify the type of x-ray or x-rays that arebeing scanned. This is done so that blank areas are not being digitizedand added to the patient's file. It will be noted that this will alsosave on transmission time to the insurance company. Further, as will bereadily appreciated by those skilled in the art, the text and image datacomprising the file can be encoded and compressed in any manner wellknown in the art in order to minimize data storage and transmittingclaimed requirements. In addition, security measures can be taken sothat only authorized persons can access the claims.

It should also be mentioned that steps S103 and S104 need not beperformed in any particular order. In an exemplary case, the patient'sx-ray may be digitized before the PAC form is called up on the computerscreen 212 and completed.

During step S105, the PAC application is formed from the electronic PACform and the digitized patient's x-ray. It should be noted that thepresent invention is not limited to a particular format for the PACapplication. For example, the format of the PAC applicationadvantageously may consist of a text file and an associated digitizedimage file. It should be noted that in this case the text and imagefiles will be transmitted seriatim. For that reason, the text file(i.e., the PAC form) and the image file (i.e., the digitized x-ray) mustcross reference one another (i.e., be correlated) so that these filescan be continuously associated with one another after transmission tothe insurance company. If the attachment is simply additional ASCIItext, e.g., Operating Room Notes, then the only step necessary is totransfer the additional ASCII text into the integrated file format. Oncein the integrated file format, all processing is the same as if the filecontained an image attachment.

In an alternative exemplary case, the PAC application advantageously canbe prepared according to the Graphic Interchange Format™ (GIF)specification, which specification is the intellectual property ofCompuServe Incorporated. In order to form the PAC application, thedigitized x-ray is converted to a GIF image file. It will be appreciatedthat the GIF image file advantageously can include one or more blocks oftextual data denoted by a comment extension, as described in Version 89aof the GRAPHICS INTERCHANGE FORMAT documentation published byCompuServe, Inc. It should be noted that since the textual informationcorresponding to the data needed to complete the PAC form is included inthe GIF image file comments, the possibility of file separation andconsequent mishandling or mismatching of the separate components of thePAC application is virtually eliminated. Alternatively, the TIFFstandard format advantageously can also be used to cojoin field anddigital image data.

It will also be appreciated that the concept of embedding comments intothe GIF or TIFF image file format is a standard practice employed bythose of ordinary skill in the art of graphic image preparation, e.g.,by photographers and digital artists who wish to identify their works.However, it should also be noted that the use of a comment block storingdata fields used in reconstructing a completed form, e.g., a completedPAC form, has never before been described or suggested. Furthermore,since the technique described above is a novel solution toelectronically forwarding an insurance claim form and an associatedattachment as one, the use of the comment block to store the PAC formfield data is likewise a unique and novel aspect according to thepresent invention.

In yet another alternative exemplary case, the digitized x-ray isautomatically added (inserted) to the electronic form by the serviceprovider's AIC software and forms a single computer file, as depicted inFIG. 5B. It should be noted that the non-text portion of the PACapplication is labeled with the same provider Document IdentificationNumber (DIN) as used on the text portion, i.e., the electronic PAC form.These two objects together now form the patient record, i.e., thepatient's PAC application. The PAC application is now ready to be sentto the insurance company.

During step S106, the service provider's office staff then transmits thecompleted PAC application to the insurance company. For example, whenthe transmission icon of the GUI AIC software running on the serviceprovider's computer system 210 is activated (e.g., “clicked” on), thefollowing substeps are automatically executed:

-   -   (a) A check is first performed to ensure that the PAC        application has been completely filled out. In the event that        problems and/or errors are noted by the AIC software, the system        user is notified of the error by an appropriate annunciator,        e.g., the suspect area can be highlighted and a message        concerning the problem and/or error could be generated and        displayed on the monitor;    -   (b) A hard copy of the PAC application is printed out, if        desired, by the service provider. The hard copy may        advantageously be placed in the patient's permanent file;    -   (c) Moreover, and more importantly, the completed PAC        application is archived in the service provider's computer        system 210, 240. It will be appreciated that this archive copy        can be accessed in several ways such as by patient name, social        security number, document identification number, etc. That is,        it can be accessed using any of the information that has been        entered into the PAC form; and    -   (d) The service provider's computer system establishes a        connection with the on-line service 400 and transmits the        patient's PAC application to the insurance companies e-mail        address. See task T1 a of FIG. 3B. It will be appreciated that        the e-mail addresses of all the insurance companies have been        stored in the AIC software residing in the memory of computer        system 210. Advantageously, the PAC application can be        transmitted immediately or can be scheduled for transmission at        a convenient time, i.e., can be transmitted after all of the PAC        applications and other forms have been prepared for the day.        Preferably, the AIC software on the service provider's computer        system 210 keeps a record of when the PAC application was sent.        In addition, the AIC software maintains and uses the proper        protocols so that when the PAC application reaches the intended        insurance company, it arrives there with the alpha-numeric        portion of computer file intact, i.e., the information is stored        in fields that can be read by the corresponding AIC software        module in the computer system 310 at the insurance company.

It should be noted that the specific transmission path taken by the PACapplication from the service provider's computer system 210 to thecomputer system 310 maintained by the insurance company is not anessential limitation of the novel system and corresponding operatingmethod according to a preferred embodiment of the present invention. Theonly requirement of a transmission path is that it maintain the digitalintegrity of the PAC application computer file. Thus, the patient's PACapplication can be sent to the insurance company in several ways usingmodems 216 and 316, including via normal phone service, an on-lineservice, or bulk data transmission lines.

In an alternative exemplary case, the completed PAC applications mayeven be transferred to tape or CD-ROM and then sent through the U.S.Postal Service 100 of FIG. 1 to the insurance company's mailroom 320.For purposes of the discussion which follows, only the exemplary case inwhich the PAC application is transmitted via the on-line service 400 isdescribed in any detail.

One of the beneficial aspects of the present invention is provided bythe combination of the customizable claim form on the service provider'scomputer 210 and the use of any non-restrictive communications channel,i.e., the insurance companies are able to freely modify informationrequirements demanded of the service providers. Existing electronicclaims processing systems, such as NEIC, are based on a clearinghouseconcept, as illustrated in FIG. 6A. In a clearing house system, allclaims enter the clearinghouse computer(s), are manipulated, and thenare transmitted to the appropriate insurance company. One consequence ofthe pure clearinghouse architecture is that it puts a constraint on theinsurance company to use a standardized claim form. The individualinsurance companies have little or no control of the information contentin the form. Moreover, because the claim form is standardized, changesare very difficult to make, i.e., any change requires that all memberinsurance companies make the change together.

In contrast, placing AIC software packages in the providers' offices andin the insurance company processing centers, where the packages arecoordinated with one another, allows every payer to transmit claim formupdates to every provider. There is no central computer that manipulatesthe claim forms. In the provider's office, the change would be reflectedprimarily in changes to the number of fields needing information and,rarely, in the addition of a new field to be completed by the provider.

As illustrated in FIG. 6B, the interchange between the provider's officeand the insurance company(ies) advantageously can be performed using anonline service or Internet Service Provider (ISP), providing that theservice provider permits 8-bit file interchanges. In that case, theupdate information could be transmitted to the provider when theprovider dials into the online service. Thus, while it is true thattransmission accomplished using e-mail involves an intermediarycomputer, the online service merely provides a mail box and places noconditions on the insurance information contained in the claim itself.

Advantageously, the non-clearinghouse architecture and coordinated AICsoftware package of the embodiment of FIG. 3B facilitates the provisionof the customizable claim form. That is, each insurance company candetermine the content of its own claim form. The packages used by theproviders are instructed regarding the information content, protocols,etc. each insurance company wants its claim to have. It will beappreciated that the package at each insurance company is designed toaccept only those claims that meet the specifications of the respectiveinsurance company. In addition, if an insurance company wants to changethe content of its claim form, it can do so independently of the otherinsurance companies.

Beneficially, the non-clearinghouse architecture reduces costs, allowsfor the direct digital interchange of data from one insurance company toanother, and permits many different types of forms to be run off thesame system, e.g. commercial insurance claims and workers' compensationclaims can both be processed in the provider's office using the samecustomizable claim form. This produces a claims processing system whichis more robust than anything on the market today.

During step S107, the PAC application is pre-processed by thevalue-added service provider 500. For example, the patient's PACapplication can be accessed by the employees of the value-added servicecompany to perform services for either the patient, the serviceprovider, or the insurance company, or any combination thereof. See taskT2 of FIG. 3B. These value-added services could include archiving of thepatient's dental x-rays so that all records for a particular patient arecentrally stored, screening of the entire PAC application for errors,compiling statistics on all PAC applications and, in some instances,even performing the review process for the insurance company.

Next, the insurance company accesses the PAC applications at the on-lineservice during step S108. In an exemplary case, each insurance companyhas an e-mail address specifically for the purpose of receiving PACapplications. An insurance company accesses its e-mail box and finds awaiting list of PAC applications which are subsequently downloaded toGUI-capable computer system 310. In a preferred embodiment as shown inFIG. 3B, the GUI-capable computer system 310 advantageously is connectedto the claims management mainframe computer 350 of the insurance company300. Preferably, the GUI-capable buffer computer system 310 is apersonal computer (PC) or a PC server which advantageously can beoperated in parallel with but separate from the insurance company'smainframe computer 350; data, however, beneficially can be interchangedbetween the buffer computer system 310 and the mainframe computer 350.In an exemplary case, as the personnel at the insurance company 300apply an insurance company document identification number (DIN) to eachreceived PAC Application, the field data contained therein is copied bythe buffer computer system 310 and transmitted to the mainframe computer350. See task T1 b of FIG. 3B.

Alternatively, the entire PAC application advantageously could be copiedby the buffer computer system 310 and downloaded to the mainframecomputer 350, where the image portion of the PAC application then can beremoved from the mainframe's memory. This approach employs basically thesame distribution of information, i.e., text form in the mainframe 350and field data and images in the buffer computer system 310.

In an exemplary case, this buffer computer 310 is part of a local areanetwork (LAN) 313, which is connected by high bandwidth cables topersonal computers or other GUI-capable terminals 311, 312 at the desks360 and 370 of the individual reviewing dentists and claims adjusters,respectively. It should be noted that the necessary AIC software hasbeen loaded onto the server 310, the individual personal computers 311,312, and the mainframe 350. Preferably, once the patient's PACapplication has been received, the system's AIC software at either thevalue-added service provider 500 or the insurance company's computer 310automatically notifies the referring service provider that the PACapplication has been received for processing, e.g., using a conventionale-mail message.

At step S109, the reviewing dentist calls up the graphics portion of thePAC application, in an exemplary case, from the server 310 to a personalcomputer 311, each of which is running the appropriate AIC software, viathe LAN 313 using the assigned DIN. See task T3 in FIG. 3B. Thereviewing dentist then calls up the text portion of the PAC applicationfrom the mainframe computer 350 using the terminal 351. See task T4 inFIG. 3B. It will be appreciated that the sequence can be reversed at thereviewing dentist's option. It should be noted that some small insurancecompanies may not even require server-LAN 310, 313 system discussedabove, but just a single PC that will incorporate the functions of theelements 310, 311, 312, and 313. In any event, the reviewing dentistcalls up a patient's PAC application using both his personal computer311 and terminal 351. When this happens, the system AIC softwareautomatically generates the insurance company's Predetermination Form onone of the two screens 311, 351. The installed AIC softwareadvantageously can automatically transfer whatever information from thePAC application to the Predetermination form that is useful incompleting the Predetermination form, e.g., repetitiveinformation/fields. For instance, the service provider's DocumentIdentification Number (PDIN) and the Provider Identification Number(PIN) can be transferred automatically to the Predetermination form. Inaddition, the AIC software can be written to display the information inthe PAC form on the screen 351 in exactly the way that this particularinsurance company wants it displayed.

In a alternative implementation, a single monitor on the computer 311supporting multiple windows, at least one of which runs terminalemulation software for displaying the output of the mainframe computer350, could advantageously be used to display both parts of the PACapplication.

With the AIC system described above, the use of “fields,” thecustomizable claim form, and the placing of coordinated AIC software atboth the service provider's office and the insurance company, haseliminated the need for standardized forms. The result is that eachinsurance company gets exactly the information it wants and has itdisplayed in exactly the way it wants. Thus, the compromise of astandardized claim form as is required with the present NEIC system isavoided.

In an exemplary case, the reviewing dentist is provided with threemonitors or a large graphics-capable monitor having a multi-page displaymode, on which can be displayed the three pages of the patient file. Itwill be appreciated that this configuration is optimized to facilitaterapid review of the PAC application. The reviewing dentist enters anInsurance Company Document Identification Number (DIN) at this point,which number is affixed to all three pages of the patient's file.

During step S110, the reviewing dentist reviews the PAC application.More specifically, the review process consists of a review of themedical facts or evidence (i.e., the text and x-ray information in thePAC application), as well as a review of the patient's insurance policy.Once the reviewing dentist has made his analysis, he goes to thePredetermination form, i.e., the third page, and enters the requiredinformation to either approve or disapprove the procedure during stepS111. The specific details regarding the information provided by thereviewing dentist will depend on the procedures established at eachindividual insurance company. Either the reviewing dentist or anotherperson, e.g., a claims adjuster, will do the review of the patient'sinsurance policy.

Advantageously, there are several ways to gain access to thisinformation. First, the server 310 can have information on every policyholder loaded into its memory. Second, the benefits reviewer, i.e.,either the reviewing dentist or the claims adjuster, can have anothermonitor 351, 352 on his desk that is connected to the company mainframecomputer 350. Thus, all that the benefits reviewer must do is select thepatient's insurance ID number and his benefits sheet will appear. Thebenefits reviewer then reads off the information that must be entered inthe Predetermination form and enters the information into the either theGUI-capable computer system 310/311/312 or the mainframe computer 350during step S111. It should again be noted that there is an electronicconnection, in the embodiment of FIG. 3B, between the mainframe computer350 and the server 310. Whatever information is deemed necessary by thatparticular insurance company to complete the Predetermination form canbe transferred between the mainframe computer 350 and the buffercomputer system 310 by entering data on one of the terminals 311, 351.See, for example, task T5 in FIG. 3B.

At this point, the Predetermination form is ready to be sent to thereferring service provider. When the transmit icon on the computerscreen of the benefit reviewer's GUI-capable computer system 311, forexample, is activated (e.g., by being “clicked” on), the followingsubsteps are automatically performed:

-   -   (a) First, a check is performed to verify that the        Predetermination form has been completely and properly filled        out. If errors are detected, the AIC software notifies the        operator via an appropriate annunciator;    -   (b) The Predetermination form and the patient's PAC application        are downloaded to the buffer computer 310. See task T5 a of FIG.        3B. From this platform, the company accesses the on-line service        400 and transmits the Predetermination form, i.e., just the        information “fields,” to the service provider's e-mail address,        which is stored in the memory of server 310. See task T6 of FIG.        3B. In the AIC software, records are kept as to which PAC        applications have been sent and when and to whom. The proper        protocols are used so that when the application reaches the        service provider, it arrives there as a computer readable file,        i.e., the information is stored in “fields” that can be read by        the AIC software at both the insurance company and the service        provider's office;    -   (c) A hard copy of the Predetermination form and x-ray are        printed, if desired, by the insurance company, see task T7 of        FIG. 3B;    -   (d) The complete patient file is archived in the insurance        company's computer system 310, 340, if desired. See task T8 of        FIG. 3B. Otherwise, just the electronic Predetermination form        and the PAC application are saved; and    -   (e) The entire three page patient file is now cleared from the        reviewing dentist's displays 311, 351 and the AIC software        prompts the reviewing dentist as to whether another patient file        should be accessed.

During step S112, the service provider accesses his e-mail address withthe on-line service 400. All Predetermination forms which have beenreceived are automatically delivered to the service provider's computersystem 210 for insertion into the appropriate patient file. The serviceprovider then reviews the Predetermination forms. Upon evaluating thedecision of the reviewing dentist, the service provider can eitherperform the procedure (if approved) or discuss the matter with thepatient's insurance company (if not approved).

During step S113, the approved procedure is performed by the serviceprovider. Once the approved procedure has been completed, the serviceprovider preferably sends in the Final Payment Claim (FPC) form. In anexemplary case, this could be as simple as just filling out anothersection of the Predetermination form and signing it using the electronicsignature pen, as discussed above. It should be noted that in FIG. 3B,this is labeled as P*. Alternatively, if the insurance company sodesires, a separate form just for this purpose can be employed. Thislatter form, which advantageously is the same customizable claim formdiscussed above, is stored in the memory of the provider's computer,must have the Insurance Company's DIN for this particular patient'sprocedure and all other needed information transferred to it, whichadvantageously can all be done by the AIC system software at step S114.At step S115, the Final Payment Claim form is transmitted back to theinsurance company. See task T9 of FIG. 3B. In an exemplary case,activating the transmit icon on the service provider's computer system210, e.g., by “clicking” on it, automatically results in the executionof the following substeps:

-   -   (a) A check is performed to see that the form has been        completely and correctly filled out. If an error has occurred,        the AIC software alerts the operator of the detected error;    -   (b) A hard copy of the form is printed out, if desired, by the        service provider;    -   (c) The complete patient's electronic file is archived in the        service provider's computer system 210, 240. It will be noted        again that the patient's electronic file can be accessed by        patient name, social security number, document identification        number, etc.; and    -   (d) The computer system 210 establishes a connection with the        on-line service and transmits the patient's Final Payment Claim        (FPC) form to the insurance company's e-mail address.

As previously discussed, the AIC software on the service provider'scomputer system 210 advantageously may include facilities fortransmitting the Final Payment Claim form to the insurance company at alater time, e.g., for transmitting all of the days PAC application andFPC forms at one time.

It will also be noted, as discussed above, that the AIC softwaremaintains records as to which claim form was sent and when it was sentto the insurance company. In an exemplary case, the e-mail address towhich the Final Payment Claim form is sent is different from the addressused in transmitting the PAC application. Since the Final Payment Claimform does not include a digitized image, i.e., a digitized x-ray, theinsurance company may choose to have the Final Payment Claim formdirected to an e-mail address accessible from the mainframe computer350. If the insurance company's processing protocol requires anindependent review of the PAC application, the Predetermination form andthe Final Payment Claim form before payment can be authorized, thee-mail address advantageously can be accessed from either the server 310or the mainframe computer 350, since these two computer systems areelectrically coupled at the insurance company 300.

The insurance company then receives the Final Payment Claim forms duringstep S116 when it accesses its Final Payment Claim forms mail box. In anexemplary case, the computer system receiving the Final Payment Claimforms is not the claims management mainframe computer 350 of theinsurance company but, rather, it is a personal computer or server 310that is part of a parallel system having an electronic connection to themainframe computer 350. This buffer computer 310 advantageously can bepart of a LAN 313. The buffer computer 310 is connected by highbandwidth cables to the personal computers or GUI-capable terminals 312located at the claims adjusters' desks. See task T10 of FIG. 3B. Itshould again be noted that the appropriate AIC software modules havebeen loaded onto the server 310, the personal computers 312 and themainframe computer 350. It will be appreciated that the informationentered in computer 312 advantageously can be automatically transferredto the mainframe 350 through the transmission path including thecomputer 312, the buffer computer 310 and the electronic connection tothe mainframe computer 350.

The Final Payment Claim form is then reviewed during step S117. Theadjuster reviewing the Final Payment Claim form can, if necessary, callup the PAC application from the memory of the server 310, since theoriginal Insurance Company Document Identification Number for thecorresponding PAC application was transferred to the Predeterminationform and, thus, to the Final Payment Claim form. In addition, theadjuster can, if need be, call up the information on the insurancepolicy of the particular patient stored in mainframe computer 350 viaterminal 352. Preferably, the insurance company provides the adjusterwith a separate monitor 352 connected to the claims management mainframecomputer 350.

Whatever internal paperwork is necessary to be filled out isautomatically downloaded with the Final Payment Claim form itself by theappropriate AIC software module. Part of this paperwork will preferablybe form(s) which must be completed so as to order a check issued to theservice provider along with an Explanation of Benefits (EOB). Also atstep S118, whatever information is necessary to be entered into themainframe 350 can be entered directly through the use of the terminal352 or indirectly through computer 312, the buffer computer 310 and theelectronic connection to the mainframe computer 350.

Finally, upon activating the transmit icon on the insurance company'spersonal computer 312, for example, the following substeps areautomatically executed:

-   -   (a) A check is again preformed to see that the form has been        completely and correctly completed and the operator is notified        if an error has occurred;    -   (b) A hard copy of the form is printed out, if desired by the        insurance company;    -   (c) The complete patient file is archived in the insurance        company's computer system, e.g., on the server. It should again        be noted that the patient file can be accessed using the        patient's name, social security number, or an assigned document        identification number, etc.; and    -   (d) A payment draft is issued, in the approved amount, to the        service provider. This can be done through any number of        methods, including printing a hard copy check and forwarding it        through the U.S. postal service, electronic funds transfer, etc.        Each form of payment will be accompanied with the normal        description of the service to which these funds should be        applied, i.e., the EOB (Explanation of Benefits).

Embodiment of FIG. 3C

In the embodiment as shown in FIG. 3C, the overall system according tothe present invention includes the computer components 200 located inthe health care provider's office and the computer components 300located on the premises of the insurance company. Infrastructure 400,which advantageously may be an existing on-line service company, andclearinghouse 600, e.g., NEIC, are preferably used in one embodiment ofthe present invention to facilitate communication between the components200 in the service provider's office and the components 300 at theinsurance company.

As shown in FIG. 3C, the components 200 include a personal computer 210including a screen 212, a keyboard 214 and a modem 216, connected to ascanner 220, a printer 230 and an archiving device 240, e.g., a largememory for storage of digital information. Device 240 advantageously maybe a writeable compact disc read only memory (CD-ROM), i.e., a so-calledwrite once-read many (WORM) device, a hard disk drive, a tape back updevice or a removable hard disk device. It should be recognized that thecomputer 210 advantageously can be a computer system including a centralprocessing unit, a graphic display processor, the graphic display device212, and several memories including both solid state memories and a harddisk drive. It should also be noted that the archive device 240 and oneof the memories associated with computer 210 may be the same memorydevice.

Components 300 located at the insurance company include the previouslydescribed mainframe or legacy computer 350 and terminals 351, 352. Inaddition, a buffer computer 310, which may be a network server, includesa modem 316 and is connected to a printer 330 and a storage device 340.The printer 320 may provide copies of documents directly to the mailroom320. Preferably, the computer 310 is connected to personal computers orwork station terminals 311, 312 via a local area network (LAN) 313.

The method for operating the system according to the embodiment of thepresent invention as depicted in FIG. 3C will now be described indetail.

The method starts at step S101 with the service provider's diagnosisthat a costly procedure is necessary. It is then determined that thepatient needs prior approval from his insurance company. During stepS102, the patient is provided with an explanation of the procedure and acost estimate for that procedure. The service provider and the patientthen prepare the needed PAC Application.

During step S103, a member of the service provider's office staffaccesses the Attachment Integrated Claims (AIC) software stored innon-volatile memory on the service provider's computer system 210, whichsoftware advantageously is Graphic User Interface (GUI) software.Preferably, this AIC software is written in C++, Visual Basic, or someother appropriate graphical programming language.

It will be appreciated that commercial software packages, such as LOTUSNOTES™, have been designed with the capability of addressingcombinations of text and graphics files. However, the purpose of thesepackages is to create an “environment” or “platform” in which specificapplications can be developed. In contrast, the preferred embodimentsaccording to the present invention are directed at providing integratedtext and graphics files within a coherent system and methodology foraddressing the specific needs of the work flow, preferably of aparticular industry. That is, it is a particular application. It ispossible, but not necessary, that the software needed to implement thepreferred embodiments of the present invention can be developed withinthe frame work of the environment created by something such as LOTUSNOTES™. Alternatively, the software needed to implement the preferredembodiments of the present invention can be written as a JAVA™ appelet.

Contained within the AIC software are PAC forms for insurance companiesusing the AIC system. When one of these is opened it acts as a templateupon which a new computer file will be based. This computer file willultimately contain the patient's PAC Application.

It will be appreciated that the PAC form when displayed on thecomputer's screen 212 contains boxes, such as those depicted in FIGS. 5Aand 5B, in which alpha-numeric characters can be entered so that, whenthe characters are entered in these boxes they are entered so as to filla “field,” a delimited alpha-numeric character string. Being a “field,”the information denoted by the characters can be transferred to and usedin completing other fields in related documents. Also, the informationitself, or lack thereof, can be used as a logic control device, e.g.,used to remind the preparer that critical information has not beenentered.

In an exemplary case, the PAC forms of many insurance companies havebeen encoded and stored in memory on the service provider's computersystem 210. This can be advantageously done in the following way. ThePAC forms for all the insurance companies using the AIC System aregathered. Then a union of all the information requested in these PACforms is made. A field is created for each element of informationrequested. For example, Field #1 contains the patient's first name,Field #2 contains the patient's last name, and so on. This is done untilthe “information fields” of the PAC forms for all of the insurancecompanies are included.

In order to increase the efficiency of the clerical staff at theprovider's office, it is desirable to give them basically the same formto fill out every time, i.e., information is always in the same place onthe form. To do this a template is created. What actually appears on thescreen of the preparer is always the same. What changes is that anygiven insurance company will desire only a particular subset of thetotal number of fields. So if insurance company A is chosen, then fields1, 2, 3, 7, 9 . . . have to be filled in, whereas, if insurance companyB is chosen, then fields 2, 3, 4, 5, 7, 11, . . . have to be filled in.The fields not needed are automatically signified in some way by the AICsoftware, e.g., if insurance company A does not need Field #4 then thatblock on the screen is gray and can't be typed into (i.e., is “writeprotected”). Thus a “customizable claim form” is provided for everyinsurance company based on a single, universal compilation of fields. Asdescribed below, what allows this method to work is that there is AICsoftware at the insurance company that has been coordinated with the AICsoftware at the providers office.

The AIC Software GUI asks for the name of the insurance company, whichcan be typed in or selected from a directory. Once the insurance companyhas been identified, the fields needed to complete the insurancecompany's PAC form are displayed on the screen 212 of the serviceprovider's computer system 210. The AIC software advantageously canautomatically fill in all the parts of the form that are specific to theservice provider, e.g., name, address, Provider Identification Number(PIN), etc. It is estimated that this alone eliminates 20% of the workneeded to fill out the PAC form. An electronic signature couldadvantageously be added at this time for the service provider or couldbe added as part of the final review and approval before the completedPAC application is transmitted.

Needed patient information is then entered into the PAC form on thecomputer screen 212, preferably while the patient is still in theoffice, and a provider Document Identification Number (PDIN) can be usedto label the form, if so desired. This is now a computer file identifiedas referring to the patient. It should be noted that some form ofsignature can be provided in the appropriate field. As an example, aspecial electronic pad and pen can be used such that when the patientsigns on the pad his signature is affixed to the electronic PAC form.

During step S104, the patient's x-ray is digitized. In an exemplarycase, there is a scanner 220, i.e., digitizer, connected to the serviceprovider's computer system running the AIC software. The patient's x-rayis scanned and converted into a series of ordered numbers (i.e., a bitmap of the x-ray image) and stored. It should be noted that these storedseries of numbers can be reconstructed by the computer system to displaythe x-ray on a computer monitor, i.e., the bit map can be used toreconstruct a raster image of the x-ray for display.

It will be appreciated that the AIC software advantageously can bewritten to minimize the time needed to scan the x-ray. In an exemplarycase, the operator can specify the type of x-ray or x-rays that arebeing scanned. This is done so that blank areas are not being digitizedand added to the patient's file. It will be noted that this will alsosave on transmission time to the insurance company. Further, as will bereadily appreciated by those skilled in the art, the text and image datacomprising the file can be encoded and compressed in any manner wellknown in the art in order to minimize data storage and transmittingclaimed requirements. In addition, security measures can be taken sothat only authorized persons can access the claims.

It should also be mentioned that steps S103 and S104 need not beperformed in any particular order. In an exemplary case, the patient'sx-ray may be digitized before the PAC form is called up on the computerscreen 212 and completed.

During step S105, the PAC application is formed from the electronic PACform and the digitized patient's x-ray. It should be noted that thepresent invention is not limited to a particular format for the PACapplication. For example, the format of the PAC applicationadvantageously may consist of a text file and an associated digitizedimage file. It should be noted that in this case the text and imagefiles will be transmitted seriatim. For that reason, the text file(i.e., the PAC form) and the image file (i.e., the digitized x-ray) mustcross reference one another (i.e., be correlated) so that these filescan be continuously associated with one another after transmission tothe insurance company. If the attachment is simply additional ASCIItext, e.g., Operating Room Notes, then the only step necessary is totransfer the additional ASCII text into the integrated file format. Oncein the integrated file format, all processing is the same as if the filecontained an image attachment.

In an alternative exemplary case, the PAC application advantageously canbe prepared according to the Graphic Interchange Format™ (GIF)specification, which specification is the intellectual property ofCompuServe Incorporated. In order to form the PAC application, thedigitized x-ray is converted to a GIF image file. It will be appreciatedthat the GIF image file advantageously can include one or more blocks oftextual data denoted by a comment extension, as described in Version 89aof the GRAPHICS INTERCHANGE FORMAT documentation published byCompuServe, Inc. It should be noted that since the textual informationcorresponding to the data needed to complete the PAC form is included inthe GIF image file comments, the possibility of file separation andconsequent mishandling or mismatching of the separate components of thePAC application is virtually eliminated. Alternatively, the TIFFstandard format advantageously can also be used to co-join field anddigital image data.

It will also be appreciated that the concept of embedding comments intothe GIF or TIFF image file format is a standard practice employed bythose of ordinary skill in the art of graphic image preparation, e.g.,by photographers and digital artists who wish to identify their works.However, it should also be noted that the use of a comment block storingdata fields used in reconstructing a completed form, e.g., a completedPAC form, has never before been described or suggested. Furthermore,since the technique described above is a novel solution toelectronically forwarding an insurance claim form and an associatedattachment as one, the use of the comment block to store the PAC formfield data is likewise a unique and novel aspect according to thepresent invention.

In yet another alternative exemplary case, the digitized x-ray isautomatically added (inserted) to the electronic form by the serviceprovider's AIC software and forms a single computer file, as depicted inFIG. 5B. It should be noted that the non-text portion of the PACapplication is labeled with the same provider Document IdentificationNumber (PDIN) as used on the text portion, i.e., the electronic PACform. These two objects together now form the patient record, i.e., thepatient's PAC application. The PAC application is now ready to be sentto the insurance company.

During step S106, the service provider's office staff then transmits thecompleted PAC application to the insurance company. For example, whenthe transmission icon of the GUI AIC software running on the serviceprovider's computer system 210 is activated (e.g., “clicked” on), thefollowing substeps are automatically executed:

-   -   (a) A check is first performed to ensure that the PAC        application has been completely filled out. In the event that        problems and/or errors are noted by the AIC software, the system        user is notified of the error by an appropriate annunciator,        e.g., the suspect area can be highlighted and a message        concerning the problem and/or error could be generated and        displayed on the monitor;    -   (b) A hard copy of the PAC application is printed out, if        desired, by the service provider. The hard copy may        advantageously be placed in the patient's permanent file;    -   (c) Moreover, and more importantly, the completed PAC        application is archived in the service provider's computer        system 210, 240. It will be appreciated that this archive copy        can be accessed in several ways such as by patient name, social        security number, document identification number, etc. That is,        it can be accessed using any of the information that has been        entered into the PAC form; and    -   (d) The service provider's computer system establishes a        connection with the on-line service 400 and transmits the        patient's PAC application to the insurance companies e-mail        address. See task T1 a of FIG. 3C. In addition, the selected        portions of the field data, i.e., the PAC form, are transmitted        to clearinghouse 600. See task T1 b of FIG. 3C. It should be        mentioned that only the digital attachment to the patient's PAC        application advantageously need be transmitted to the insurance        company 300 using the online service 400. However, since        transmission of the entire PAC application insures that the        complete PAC application is available to the insurance company,        the provider's office 200 preferably transmits the entire PAC        application to the insurance company 300.

It will also be appreciated that the e-mail addresses of all theinsurance companies have been stored in the AIC software residing in thememory of computer system 210. Advantageously, the digital attachmentand field data forming the PAC application can be transmittedimmediately or can be scheduled for transmission at a convenient time,i.e., can be transmitted after all of the PAC applications and otherforms have been prepared for the day. Preferably, the AIC software onthe service provider's computer system 210 keeps a record of when thePAC application was sent. In addition, the AIC software maintains anduses the proper protocols so that when the PAC application reaches theintended insurance company, it arrives there with the alpha-numericportion of computer file intact, i.e., the information is stored infields that can be read by the corresponding AIC software module in themainframe computer 350 at the insurance company 300.

It should be noted that the specific transmission path taken by the PACapplication from the service provider's computer system 210 to thecomputer system 310 maintained by the insurance company is not anessential limitation of the novel system and corresponding operatingmethod according to a preferred embodiment of the present invention. Theonly requirement of a transmission path is that it maintain the digitalintegrity of the PAC application computer file. Thus, the patient's PACapplication can be sent to the insurance company in several ways usingmodems 216 and 316, including via normal phone service, the on-lineservice 400, or bulk data transmission lines.

In an alternative exemplary case, the completed PAC applications mayeven be transferred to tape or CD-ROM and then sent through the U.S.Postal Service 100 of FIG. 1 to the insurance company's mailroom 320.For purposes of the discussion which follows, only the exemplary case inwhich the digital attachment for the PAC application is transmitted viathe on-line service 400 is described in any detail.

One of the beneficial aspects of the present invention is provided bythe combination of the customizable claim form on the service provider'scomputer 210 and the use of any non-restrictive communications channel,i.e., the insurance companies are able to freely modify informationrequirements demanded of the service providers. Existing electronicclaims processing systems, such as NEIC, are based on a clearinghouseconcept, where all claims entering the clearinghouse computer(s), aremanipulated, and then are transmitted to the appropriate insurancecompany. One consequence of the clearinghouse architecture alone is thatit puts a constraint on the insurance company to use a standardizedclaim form. The individual insurance companies have no control of theinformation content in the form. Moreover, because the claim form isstandardized, changes are very difficult to make, i.e., any change wouldrequire all member insurance companies to make the change together.

In contrast, placing AIC software packages in the providers' offices andin the insurance company processing centers, where the packages arecoordinated with one another, allows every payer to transmit claim formupdates to every provider. In the provider's office, the change would bereflected primarily in changes to the number of fields needinginformation and, rarely, in the addition of a new field to be completedby the provider. Transfer of this additional or supplemental informationbetween the provider's office and the insurance company(ies)advantageously can be performed using an online service or InternetService Provider (ISP), providing that the service provider permits8-bit file interchanges. In that case, the update information could betransmitted to the provider when the provider dials into the onlineservice.

Advantageously, the simultaneous use of both clearinghouse andnon-clearinghouse architectures and coordinated AIC software packages ofthe embodiment of FIG. 3C facilitates the provision of the customizableclaim form. That is, each insurance company can determine the content ofits own claim form. The packages used by the providers are instructedregarding the information content, protocols, etc. each insurancecompany wants its claim to have. In addition, if an insurance companywants to change the content of its claim form, it can do soindependently of the other insurance companies, since the additionalinformation is not transmitted via clearinghouse 600.

Beneficially, the simultaneous use of both clearinghouse andnon-clearinghouse architectures reduces costs, allows for the directdigital interchange of data from one insurance company to another, andpermits many different types of forms to be run off the same system,e.g. commercial insurance claims and workers' compensation claims canboth be processed in the provider's office using the same customizableclaim form. This produces a claims processing system which is morerobust than anything on the market today.

During step S107, the PAC application is processed by the clearinghouse600. Then, the insurance company accesses the PAC applications at theon-line service during step S108 and the PAC form of the PAC applicationat clearinghouse 600. In an exemplary case, each insurance company hasan e-mail address specifically for the purpose of receiving the PACapplications. An insurance company accesses its e-mail box and finds awaiting list of PAC applications which are subsequently downloaded toGUI-capable computer system 310. In a preferred embodiment as shown inFIG. 3C, the GUI-capable computer system 310 is separate from the claimsmanagement mainframe computer 350 of the insurance company 300.Preferably, the GUI-capable buffer computer system 310 is a personalcomputer (PC) or a PC server which advantageously can be operated inparallel with but separate from the insurance company's mainframecomputer 350.

In an exemplary case, this buffer computer 310 is part of a local areanetwork (LAN) 313, which is connected by high bandwidth cables topersonal computers or other GUI-capable terminals 311, 312 at the desks360 and 370 of the individual reviewing dentists and claims adjusters,respectively. It should be noted that the necessary AIC software hasbeen loaded onto the server 310 and onto the individual personalcomputers 311, 312. Preferably, once the patient's PAC application hasbeen received, the system's AIC software at the insurance company'scomputer 310 automatically notifies the referring service provider thatthe PAC application has been received for processing, e.g., using aconventional e-mail message.

At step S109, the reviewing dentist calls up the PAC application, in anexemplary case, from both the server 310 to a personal computer 311 viathe LAN 313 and the PAC form from the mainframe computer 350 to theterminal 351. See tasks T3 and T4 in FIG. 3C. It will be appreciatedthat all of the computers 310, 311 and 350 at insurance company 300 are,in the exemplary case, running AIC software. It should be noted thatsome small insurance companies may not even require server-LAN 310, 313system discussed above, but just a single PC that will incorporate thefunctions of the elements 310, 311, 312, and 313. In any event, thereviewing dentist calls up a patient's PAC application on his personalcomputer 311 and terminal 351. When this happens, the system AICsoftware automatically inserts the insurance company's PredeterminationForm into this file on, in an exemplary case, the buffer computer 310(mainframe computer 350). The installed AIC software on buffer computer310 (mainframe computer 350) advantageously can automatically transferwhatever information from the PAC form of the PAC application to thePredetermination form that is useful in completing the Predeterminationform, e.g., repetitive information/fields. For instance, the serviceprovider's Document Identification Number (PDIN) and the ProviderIdentification Number (PIN) can be transferred automatically to thePredetermination form. In addition, the AIC software can be written todisplay the information in the PAC form on the screen 311 (screen 351)in exactly the way that this particular insurance company wants itdisplayed.

With the AIC system described above, the use of “fields,” thecustomizable claim form, and the placing of coordinated AIC software atboth the service provider's office and the insurance company, haseliminated the problems associated with standardized forms. In short,the insurance company can elect to receive the PAC application, thedigital attachment and desired field data, or the digital attachmentalone from the computer 210 in the provider's office 200. The result isthat each insurance company gets exactly the information it wants andhas it displayed in exactly the way it wants. Thus, the compromise of astandardized claim form, as is required when using the NEIC systemalone, is avoided.

In an exemplary case, the reviewing dentist is provided with twomonitors on which can be displayed the three pages of the patient file.It will be appreciated that this configuration is optimized tofacilitate rapid review of all parts of the PAC application. Thereviewing dentist enters an Insurance Company Document IdentificationNumber (DIN) at this point, which number is affixed to all three pagesof the patient's file.

During step S110, the reviewing dentist reviews the PAC application.More specifically, the review process consists of a review of themedical facts or evidence (i.e., the text and x-ray information indigital attachment of the PAC application using computer 311), as wellas a review of the patient's insurance policy on terminal 351. Once thereviewing dentist has made his analysis, he goes to the Predeterminationform, i.e., the third page, and enters the required information toeither approve or disapprove the procedure during step S111. Thespecific details regarding the information provided by the reviewingdentist will depend on the procedures established at each individualinsurance company. Either the reviewing dentist or another person, e.g.,a claims adjuster, will do the review of the patient's insurance policy.It will be appreciated that the benefits reviewer, i.e., either thereviewing dentist or the claims adjuster, need only select the patient'sinsurance ID number and his benefits sheet will be retrieved by themainframe computer 350 for display on terminal 351. The benefitsreviewer then reads off the information that must be entered in thePredetermination form and enters the information into, in an exemplarycase, the computer system 310 (mainframe computer 350) using computer311 (terminal 351) during step S111. It should again be noted that thereis no electronic connection, in the preferred embodiment, between themainframe computer 350 and the server 310. The reviewer can, at thistime, also enter whatever additional information is deemed necessary bythat particular insurance company into the mainframe computer 350. Seetask T5 in FIG. 3C.

Thus, in alternative exemplary cases, the Predetermination formadvantageously can be completed by entering needed data into themainframe 350 using the terminal 351 or it can be completed by enteringneeded data into the buffer computer 310 using the computer 311.Preferably, the completed Predetermination form is transmitted to theprovider's office 200 either from the buffer computer 310 via the onlineservice 400 or from the mainframe computer 350 using the clearinghouse600, whichever is most convenient for the insurance company 300.

At this point, the Predetermination form is ready to be sent to thereferring service provider. When the transmit icon on the computerscreen of the benefit reviewer's computer 311 is activated, thefollowing substeps are automatically performed:

-   -   (a) First, a check is performed to verify that the        Predetermination form has been completely and properly filled        out. If errors are detected, the AIC software notifies the        operator via an appropriate annunciator;    -   (b) The Predetermination form and the patient's PAC application        are downloaded to the buffer computer 310. See task T5 of FIG.        3C. From this platform, the company accesses the on-line service        400 and transmits the Predetermination form, i.e., just the        information “fields,” to the service provider's e-mail address,        which is stored in the memory of server 310. See task T6 of FIG.        3C. In the AIC software, records are kept as to which PAC        applications have been sent and when and to whom. The proper        protocols are used so that when the application reaches the        service provider, it arrives there as a computer readable file,        i.e., the information is stored in “fields” that can be read by        the AIC software at both the insurance company and the service        provider's office;    -   (c) A hard copy of the Predetermination form and x-ray are        printed, if desired, by the insurance company, see task T7 of        FIG. 3C;    -   (d) The complete patient file is archived in the insurance        company's computer system 310, 340, if desired. See task T8 of        FIG. 3C. Otherwise, just the electronic Predetermination form        and the PAC application are saved; and    -   (e) The entire three page patient file is now cleared from the        reviewing dentist's display 311 and the AIC software prompts the        reviewing dentist as to whether another patient file should be        accessed.

During step S112, the service provider accesses his e-mail address withthe on-line service 400. All Predetermination forms which have beenreceived are automatically delivered to the service provider's computersystem 210 for insertion into the appropriate patient file. The serviceprovider then reviews the Predetermination forms. Upon evaluating thedecision of the reviewing dentist, the service provider can eitherperform the procedure (if approved) or discuss the matter with thepatient's insurance company (if not approved).

During step S113, the approved procedure is performed by the serviceprovider. Once the approved procedure has been completed, the serviceprovider preferably sends in the Final Payment Claim (FPC) form. In anexemplary case, this could be as simple as just filling out anothersection of the Predetermination form and signing it using the electronicsignature pen, as discussed above. It should be noted that in FIG. 3C,this is labeled as P*. Alternatively, if the insurance company sodesires, a separate form just for this purpose can be employed. Thislatter form, which advantageously is stored in the memory of theprovider's computer 210, must have the Insurance Company's DIN for thisparticular patient's procedure and all other needed informationtransferred to it, which advantageously can all be done by the AICsystem software at step S114. At step S115, the Final Payment Claim formis transmitted back to the insurance company. See task T9 of FIG. 3C. Inan exemplary case, activating the transmit icon on the serviceprovider's computer system 210, e.g., by “clicking” on it, automaticallyresults in the execution of the following substeps:

-   -   (a) A check is performed to see that the form has been        completely and correctly filled out. If an error has occurred,        the AIC software alerts the operator of the detected error;    -   (b) A hard copy of the form is printed out, if desired, by the        service provider;    -   (c) The complete patient's electronic file is archived in the        service provider's computer system 210, 240. It will be noted        again that the patient's electronic file can be accessed by        patient name, social security number, document identification        number, etc.; and    -   (d) The computer system 210 establishes a connection with the        clearinghouse 600 and transmits the patient's Final Payment        Claim (FPC) form to the insurance company's e-mail address.

As previously discussed, the AIC software on the service provider'scomputer system 210 advantageously may include facilities fortransmitting the Final Payment Claim form to the insurance company at alater time, e.g., for transmitting all of the days PAC application andFPC forms at one time.

It will also be noted, as discussed above, that the AIC softwaremaintains records as to which claim form was sent and when it was sentto the insurance company. In an exemplary case, the e-mail address towhich the Final Payment Claim form is sent is different from the addressused in transmitting the PAC application. Since the Final Payment Claimform does not include a digitized image, i.e., a digitized x-ray, theinsurance company may choose to have the Final Payment Claim formdirected to an e-mail address accessible from the mainframe computer350.

The insurance company then receives the Final Payment Claim forms duringstep S116 when it accesses its Final Payment Claim forms mail box. In anexemplary case, the computer system receiving the Final Payment Claimforms is the claims management mainframe computer 350 of the insurancecompany 300. The Final Payment Claim form is retrieved from mainframecomputer 350 using the terminal 352 located at the claims adjusters'desk. See task T10 of FIG. 3C. Alternatively, the Final Payment Claimform advantageously can be retrieved from buffer computer 310 using thecomputer 312 located at the claims adjusters' desk when the FinalPayment Claim form is addressed to the buffer computer, i.e., server,310. It should again be noted that the appropriate AIC software moduleshave been loaded onto the server 310, the personal computer 312 and themainframe computer 350.

The Final Payment Claim form is then reviewed during step S117. Theadjuster reviewing the Final Payment Claim form can, if necessary, callup the PAC application from the memory of the server 310, since theoriginal Insurance Company Document Identification Number for thecorresponding PAC application was transferred to the Predeterminationform and, thus, to the Final Payment Claim form. In addition, theadjuster can, if need be, call up the information on the insurancepolicy of the particular patient. Preferably, the insurance company 300provides the adjuster with a separate monitor 352 connected to theclaims management software on mainframe computer 350.

Whatever internal paperwork is necessary to be filled out isautomatically downloaded with the Final Payment Claim form itself by theappropriate AIC software module. Part of this paperwork will preferablybe form(s) which must be completed so as to order a check issued to theservice provider along with an Explanation of Benefits (EOB). Also atstep S118, whatever information is necessary to be entered into themainframe can be done through the use of the terminal 352.

Finally, upon activating the transmit icon on the insurance company'spersonal computer 312 (terminal 352), the following substeps areautomatically executed:

-   -   (a) A check is again preformed to see that the form has been        completely and correctly completed and the operator is notified        if an error has occurred;    -   (b) A hard copy of the form is printed out, if desired by the        insurance company;    -   (c) The complete patient file is archived in the insurance        company's computer system, e.g., on the server. It should again        be noted that the patient file can be accessed using the        patient's name, social security number, or an assigned document        identification number, etc.; and    -   (d) A payment draft is issued, in the approved amount, to the        service provider. This can be done through any number of        methods, including printing a hard copy check and forwarding it        through the U.S. postal service, electronic funds transfer, etc.        Each form of payment will be accompanied with the normal        description of the service to which these funds should be        applied, i.e., the EOB (Explanation of Benefits).

The preferred embodiments of FIGS. 3A-3C were described as transmittingdigitized dental x-rays as part of an integrated PAC application filetransmitted between a service provider and an insurance company.However, the present invention is broadly directed to the integratedtransmission of any “electronic text form” and any “attachment.”Further, the present invention is not limited to transmissions betweenproviders and insurance companies. Rather, it is intended to facilitatethe transmission of electronic forms with attachments between any personor organization and any other person or organization.

For example, the present invention has utility in such other areas asProperty/Casualty Insurance and law enforcement. Thus, the “attachment”need not be an x-ray or other type of image. Rather it can be anyinformation which is not easily incorporated into an associated“electronic text form” and/or cannot be easily displayed on an existinglegacy computer system. Attachments can include, but are not limited to,pictures, graphs, sound recordings, and nonstandard text. Examples wouldbe x-rays, CTs, MRIs, EKG or EEG recordings, i.e., strip charts,digitized video signals such as Moving Picture Experts Group (MPEG)compressed video signals, transcriptions of Operating Room Notes,estimates for repairs to a house or car, EOBs (Explanation of Benefits),additional ASCII text, and the like. As used in this description, allparticulars regarding a specific “attachment,” such as medicalspecialty, acquiring modality, the patient's problem, etc., can beignored. These are details having absolutely no bearing on the essenceof the present invention. The only requirements are that the informationmust be something that can be digitized and therefore put into the formof a computer file, and that once in this form, it can be “read,reviewed or interpreted” by the person or organization receiving it.

The exemplary preferred embodiment as depicted in FIG. 3A and discussedabove address only a stand-alone system of computers, which isindependent of the practice management software in the local dentist'soffice, the claims management software at each insurance company, and ofclearinghouses such as NEIC. However, from the embodiments as depictedin FIGS. 3B and 3C, it will be appreciated that there is an entirespectrum of different ways to structure a system which will support“attachment integrated claims” which will be readily apparent to aperson of ordinary skill in the art (after having the benefit of thepresent disclosure), all of which are encompassed by the presentinvention.

It should also be noted that the AIC software described thus far hasbeen independent of the service provider's practice management software.However, one alternative preferred embodiment calls for integrating theAIC software with the practice management software. This would furtherreduce the amount of time spent actually filling out the PAC applicationand the other paperwork involved in the overall claims process.

Electronic filing of standard 100% text claims is now being supported bymany practice management systems and by stand-alone electronic claimssoftware systems. In another alternative preferred embodiment, the AICsoftware could be incorporated into these systems as a means of sendingthe x-ray part of the PAC application.

It should also be mentioned that the present invention represents atotal solution on three levels to the problem of streamlining theprocessing of insurance claim forms with attachments. First, the systemfrom provider to third party payer is totally digital. The presentinvention includes an integrated system of hardware and AIC softwarethat allows: (1) providers to create an electronic (digital) version ofa patient's PAC application (text and x-ray); (2) providers to transmitthe PAC application to an insurance company; and (3) the insurancecompany to read the patient's PAC application. Thus, it creates acoherent system for the filing, transmission and processing of “claimswith attachments.”

Secondly, the present invention is an industry-wide system which allowsevery provider to interface with every third party payer. Finally, thepresent invention is a system which permits all communications betweenthe service provider and the insurance company to be totally electronic.The present invention makes the entire process electronic from theinitial preparation of the PAC form to the payment of the final claim.Communication is digital in both directions.

As discussed above with reference to FIGS. 3A-3B, the patient, theservice provider, the insurance company, or any combination thereof mayprefer that all communication be performed through a value-added serviceprovider 500. Also, it should be mentioned that for the embodimentdepicted in FIG. 3C, since the PAC application, i.e., PAC form anddigital attachment, can be transmitted to the insurance company 300using an online service while only the PAC form is transmitted to theinsurance company 300 using the clearinghouse 600, the patient, theservice provider, the insurance company, or any combination thereof mayprefer that all communication be performed through a value added serviceprovider (not shown in FIG. 3C) connected to the online service 400. Theservices performed by the value added service provider in each of theembodiments described with reference to FIGS. 3A-3C advantageously couldinclude any or all of the services listed immediately below.

First, the value-added service provider 500 may act as a National DentalData Bank (NDDB), i.e., a data bank storing patient dental images.Limited information regarding the patient from the PAC form is attachedto the digital x-ray to produce a digitized x-ray record. Thisinformation could include, for example, the date that the x-ray wastaken, the identity of the service provider who took the x-ray, thepatient's name and social security number, etc. The digitized x-rayrecord is archived at NDDB for the patient. This would allow theretrieval of the x-ray by the patient at any time for any reason, e.g.,the patient could ask that the x-ray and claim be sent to anotherdentist for a second opinion and/or for a second price estimate. Infact, the patient may request that the PAC application be sent to otherqualified service providers so that they could competitively bid on theneeded procedure.

In addition to the NDDB function, the value-added service provider 500could perform prescreening of the PAC applications for errors and couldprovide statistics to both the service providers and the insurancecompanies regarding, for example, the frequency at which a procedure isperformed or the frequency at which follow up treatment is requiredafter a first procedure is performed. The value-added service provider500 could also do the prior approval review for an insurance company orcould provide other services tailored to suit the needs of the serviceprovider, the patient, and/or the individual insurance company.

It should be mentioned that there are three outside areas of softwarethat advantageously can be taken into consideration, or ignored, withthe present invention. These are practice management software run by theservice provider, claims management software run by the insurancecompany, and clearinghouse software. The present invention allows forthe entire spectrum of interfacing, from a totally stand-alone systemfor electronic claims processing to one that is fully integrated withpractice management software, claims management software, and the NEIC.Moreover, the present invention is specifically contrived so that it canbe used simultaneously in all modes. That is, one insurance companycould choose to have no interfacing between the computer 310 running theAIC software and its mainframe computer 350, while, at the same time,another insurance company could choose to have AIC software runningsimultaneously on both the mainframe computer 350 and the buffercomputer system 310. Thus, each operating mode or methodology could beconsidered to be a different preferred embodiment of the presentinvention, notwithstanding the fact that all modes are expected to beoperating simultaneously.

The present invention was motivated by a desire to solve a problem whichhas existed for many years. The AIC software was designed with this inmind. Thus, for example, redundant information is automatically movedfrom one form and file to another along the chain of operating steps,i.e., from one document to another within a given insurance company'sset of forms. Moreover, the AIC software advantageously can be writtenin C++ or some other appropriate programming language. The reason forthis is so that when information in entered into areas of the electronicPAC forms, it is entered as a “field.” Being a “field” it can be used asa logic control device, as discussed in greater detail above.

The overall workflow problem to be addressed is treated as a coherentwhole. Thus, AIC software is specifically designed so that, at each stepof the preferred operating method, the fact that the information is indigital form is used to streamline the process. Thus, the AIC softwareis designed to eliminate inefficiencies and deficiencies that exist incurrent claims handling systems. For example, the information itself canbe used as a logical control device and it can also be transferred fromone document to another. It should be noted that all available forms arewritten into the AIC software so that they are coordinated with oneanother, that is, they know where each has a similar “field.”

It should also be noted that the AIC software automates much of theoverall insurance claims processing, thus eliminating many of the areasthat are repetitive or prone to human error. These areas include thefollowing:

-   -   (a) Filling in the service provider's information. Although each        insurance company may require something different in the way of        service provider information, the AIC software can store        consolidated service provider information so that the        information need be entered only once. For example, the service        provider need only enter his telephone number once; the AIC        software can reformat this basic information specifically for        each individual insurance company's form;    -   (b) Transmitting the PAC application to the correct e-mail        address, thus eliminating the errors associated with hand        addressing and stamping the mailing envelope;    -   (c) Checking each completed form, i.e., PAC application and        Predetermination form, for accuracy and completeness, while it        is still at the provider's office or the insurance company; and    -   (d) Simultaneously transmitting, archiving, and printing the        completed forms, e.g., the PAC application.

It will be appreciated that many such advantages will be evident tothose of ordinary skill in the art from having the requisite PAC formstored in the AIC software on the service provider's computer system210, 240.

Moreover, the AIC system advantageously can be optimized to limitunnecessary information. For example, the system can make use ofscanners 220 which have portions of their scanning area physically orelectronically masked out, which reduces both scanning time andtransmission time by minimizing the size of the digitized x-rayproduced, for example, during step S104. The provisions for the use ofdigital and digitized signatures also eliminates unneeded papershuffling.

It should again be noted that the major improvement in efficiencyattributable to the AIC system results from combining or coordinating anelectronic PAC form with an electronic (digitized) x-ray. Thiselectronic x-ray will have a document identification number assigned toit.

In addition, the AIC system and corresponding method according topreferred embodiments of the present invention provide severalconvenience features which are only possible when using a fullyelectronic filing system. For example, the AIC system facilitatesautomatic acknowledgment by the insurance company that it has receivedthe PAC application. Moreover, the AIC system provides automatictransfer of pertinent information from the PAC application to thePredetermination form. Furthermore, the AIC system components at theinsurance company preferably allow simultaneous viewing of the threedocuments needed to complete the Predetermination form. In addition, theAIC system and requisite software automates the entire transmitting andarchiving processes of the PAC application and the Predetermination format the insurance company.

In some instances, the electronic reuse of the Predetermination form asthe Final Payment Claim form means that the service provider need onlyindicate the date that the procedure was performed and enter the serviceprovider's facsimile or electronic signature. The AIC software module atthe provider's office requests these be entered into P, i.e., thePredetermination form, to create P*, i.e., the Final Payment Claim form,and then transmits P* to the final claims e-mail address for payment.Moreover, the only information that needs to be sent from the serviceprovider to the insurance company is the insurance company's assigneddocument identification number, the date of completion and the serviceprovider's signature.

The preferred embodiments of the AIC system according to the presentinvention provide dentists in the field with the necessary hardware andsoftware which allows them to create an electronic (digital) version ofa patient's PAC application, both the text and the required patientx-ray. The AIC software automatically adds these two data types togetherto form a single entity, the patient's PAC application. Moreover, theAIC system provides the insurance companies with hardware and softwarewhich allows them to read the patient's electronic PAC application. Foreach insurance company, this application is tailored so that it containsthe specific information required by that company and it contains thatinformation in the form required by that company. As such, the necessityto force standard formats on the insurance industry is eliminated.Moreover, the AIC system and software automatically attaches a partiallyfilled out Predetermination form to the patient's PAC application whenit is called up for review and approval. Moreover, the AIC system andsoftware completely eliminates the time consuming process of actuallyhandling the patient's film x-ray by insurance company personnel.

Other modifications to and variations of the invention will be apparentto those skilled in the art from the foregoing disclosure and teachings.Thus, while only certain embodiments of the invention have beenspecifically described herein, it will be apparent that numerousmodifications may be made thereto without departing from the spirit andscope of the invention, as defined in the appended claims.

What is claimed is:
 1. A computer implemented method, for processinginsurance transactions that require attachments, the method comprisingthe steps of: receiving digital data at a first computer, wherein thedigital data comprises a first computer file and a second computer file,both of which contain information about a particular insuranceencounter; wherein at least some of the digital data in the firstcomputer file and at least some of the digital data in the secondcomputer file are in a first set of identifiable data fields; whereinthe first computer file and the second computer file arecross-referenced with each other; wherein the first computer filecontains at least attachment data and the second computer file containsat least insurance transaction data; wherein at least some of theinsurance transaction data and the attachment data comprise digital datain the first set of identifiable data fields; examining via the firstcomputer the identifiable fields of the digital data to determine whichfields contain insurance transaction data and which fields containattachment data; storing first digital data in the first computer,wherein the first digital data comprises at least some of the attachmentdata; transmitting second digital data from the first computer to asecond computer, wherein the second digital data comprises at least someof the insurance transaction data; storing the second digital data inthe second computer, wherein the insurance transaction data stored inthe second computer and the attachment data stored in the first computerare cross-referenced with each other; wherein at least some of the dataincluded in the first digital data is excluded from the second digitaldata; and processing an insurance transaction by entering data into atleast one identifiable field in a second set of identifiable data fieldsusing at least some of the data in the first set of identifiable datafields in a logic process to determine the data to be entered into theat least one identifiable field in the second set of identifiable datafields.
 2. The method of claim 1, wherein the excluded data comprises atleast some of the attachment data.
 3. The method of claim 1, wherein theprocessing step comprises displaying at least some of said insurancetransaction data and said attachment data on at least one computerdisplay device.
 4. The method of claim 1, wherein the processing stepcomprises inputting data into a form using a data inputting device. 5.The method of claim 4, wherein the inputting device comprises akeyboard.
 6. The method of claim 4, wherein the form is selected fromthe group consisting of an explanation of benefits form, a payment form,and a predetermination form.
 7. The method of claim 1, wherein the atleast some of the insurance transaction data transmitted from the firstcomputer to the second computer is data in a subset of the first set ofidentifiable data fields.
 8. The method of claim 7, wherein the subsetof the first set of identifiable data fields is specified using theidentities of the fields.
 9. The method of claim 1, wherein theprocessing step comprises using data from at least one of theidentifiable data fields in the first set of identifiable data fields tocomplete at least one identifiable field in an electronic form.
 10. Themethod of claim 9, wherein the form is selected from the groupconsisting of an explanation of benefits form, a payment form, and apredetermination form.
 11. The method of claim 9, wherein the methodfurther comprises the step of transmitting said form to a computeroperated for a provider.
 12. The method of claim 11, wherein theprovider is a healthcare provider.
 13. The method of claim 9, whereinthe method further comprises the step of archiving said form as acomputer file.
 14. The method of claim 9, wherein the method furthercomprises the step of storing at least some of the data in said form inidentifiable data fields.
 15. The method of claim 1, wherein theentering step comprises completing at least one identifiable data fieldin an explanation of benefits statement, a payment statement, apredetermination statement, or a database.
 16. The method of claim 1,wherein the method further comprises the step of transmitting at leastsome of the completed second set of identifiable data fields to acomputer operated for a provider.
 17. The method of claim 16, whereinthe provider is a healthcare provider.
 18. The method of claim 1,wherein the method further comprises the step of accessing at least oneof the first and the second digital data using the cross-referencingdata.
 19. The method of claim 1, wherein the first digital datacomprises data in a first set of N₁ identifiable data fields, and thesecond digital data comprises data in a second set of N₂ identifiabledata fields.
 20. The method of claim 1, wherein the receiving stepcomprises receiving a computer file comprising the digital data.
 21. Themethod of claim 1, wherein the receiving step comprises the steps of:receiving the first computer file comprising at least some of theattachment data, and receiving the second computer file comprising atleast some of the insurance transaction data, wherein at least some ofthe data included in the first computer file is excluded from the secondcomputer file.
 22. The method of claim 21, wherein the excluded datacomprises at least some attachment data.
 23. The method of claim 1,wherein the method further comprises the step of archiving at least someof the digital data as a computer file.
 24. The method of claim 1,wherein the method further comprises the step of storing at least someof the digital data in identifiable data fields.
 25. The method of claim1, wherein the received digital data comprises cross-referencing datafor associating the insurance transaction data with the attachment data.26. The method of claim 1, wherein the method further comprises the stepof cross-referencing the insurance transaction data and the attachmentdata.
 27. The method of claim 1, wherein the cross-referencing datacomprises at least one identification number.
 28. The method of claim 1,wherein the cross-referencing data comprises at least one selected fromthe group consisting of at least one identification number, at leastsome of the insurance transaction data, healthcare provider documentidentification data, insurance payer document identification data,healthcare payer document identification data, healthcare transactionidentification data, identification number, healthcare-insurance-claimattachment identification number, and data that identifies a healthcareencounter.
 29. The method of claim 1, wherein the computer system isoperated for an insurance payer.
 30. The method of claim 29, wherein theinsurance payer is selected from the group consisting of a dentalinsurance payer, a medical insurance payer, a healthcare insurancepayer, a property insurance payer, a worker's compensation insurancepayer, and casualty insurance payer.
 31. The method of claim 30, whereinthe first computer comprises a buffer computer system and the secondcomputer comprises a legacy computer system.
 32. The method of claim 31,wherein the legacy computer system is a health-insurance-claimsmanagement computer system.
 33. The method of claim 32, wherein theattachment data is health-insurance-claims attachment data and theinsurance transaction data is health-insurance-claims data.
 34. Themethod of claim 31, wherein said buffer computer system is configured bysoftware for displaying at least some of said attachment data on acomputer display device.
 35. The method of claim 1, wherein thereceiving step comprises receiving the digital data from a computersystem operated for at least one selected from the group consisting of avalue added service, a provider, an insurance provider, a healthcareprovider, and a clearinghouse.
 36. The method of claim 1, wherein theinsurance transaction data comprises information selected from the groupconsisting of dental data, medical data, healthcare data, worker'scompensation data, property and casualty insurance transactioninformation.
 37. The method of claim 1, wherein the insurancetransaction data comprises at least one selected from the groupconsisting of an identification number, transaction identification data,beneficiary information, beneficiary name, patient data, patient name,healthcare provider data, healthcare provider name, healthcare provideridentification data, healthcare provider document identification data,healthcare payer identification data, healthcare payer name, healthcarepayer identification number, healthcare payer document identificationdata, healthcare-insurance-claim attachment identification number,description of service provided, date of service, healthcare encounterinformation, prior approval claim data, and worker's compensation data.38. The method of claim 1, wherein the attachment data comprises anattachment selected from a group consisting of a picture, a graph, asound recording, nonstandard text, a digitized x-ray, an explanation ofbenefits, a CT, an MRI, a EKG, a EEG, a strip chart, a digitized videosignals, a transcription of operating room notes, supplemental data to ahealth insurance claims, and additional ASCII text.
 39. The method ofclaim 1, wherein the transmitting step includes transmitting thecross-referencing data from the first computer to the second computer.40. The method of claim 1, wherein the second data comprises only aportion of the at least some of the insurance transaction datatransmitted from the first computer to the second computer.
 41. Acomputer system configured to process insurance transactions thatrequire attachments, the computer system comprising: first and secondcomputers; memory; and software in the memory configured to cause thecomputer system to: receive digital data at the first computer, whereinthe digital data comprises a first computer file and a second computerfile, both of which contain information about a particular insuranceencounter; wherein at least some of the digital data in the firstcomputer file and at least some of the digital data in the secondcomputer file are in a first set of identifiable data fields; whereinthe first computer file and the second computer file arecross-referenced with each other; wherein the first computer filecontains at least attachment data and the second computer file containsat least insurance transaction data; wherein at least some of theinsurance transaction data and the attachment data comprise digital datain the first set of identifiable data fields; examine via the computersystem the identifiable fields of the digital data to determine whichfields contain insurance transaction data and which fields containattachment data; store first digital data in the first computer, whereinthe first digital data comprises at least some of the attachment data;transmit second digital data from the first computer to the secondcomputer, wherein the second digital data comprises at least some of theinsurance transaction data; store the second digital data in the secondcomputer; wherein the insurance transaction data stored in the secondcomputer and the attachment data stored in the first computer arecross-referenced with each other; wherein at least some of the dataincluded in the first digital data is excluded from the second digitaldata; and process an insurance transaction by entering data into atleast one identifiable field in a second set of identifiable data fieldsusing at least some of the data in the first set of identifiable datafields in a logic process to determine the data to be entered into theat least one identifiable field in the second set of identifiable datafields.
 42. The computer system of claim 41, wherein the excluded datacomprises at least some of the attachment data.
 43. The computer systemof claim 41, wherein the processing of the insurance transactioncomprises displaying at least some of said insurance transaction dataand said attachment data on at least one computer display device of thecomputer system.
 44. The computer system of claim 41, wherein theprocessing of the insurance transaction comprises inputting data into aform using a data inputting device.
 45. The computer system of claim 44,wherein the data inputting device comprises a keyboard.
 46. The computersystem of claim 44, wherein the form is selected from the groupconsisting of an explanation of benefits form, a payment form, and apredetermination form.
 47. The computer system of claim 41, wherein theat least some of the insurance transaction data transmitted from thefirst computer to the second computer is data in a subset of the firstset of identifiable data fields.
 48. The computer system of claim 47,wherein the subset of the first set of identifiable data fields isspecified using the identities of the fields.
 49. The computer system ofclaim 41, wherein the processing of the insurance transaction comprisesthe computer system using data from at least one of the identifiabledata fields in the first set of identifiable data fields to complete atleast one identifiable field in an electronic form.
 50. The computersystem of claim 49, wherein the form is selected from the groupconsisting of an explanation of benefits form, a payment form, and apredetermination form.
 51. The computer system of claim 49, wherein thesoftware further adapts the computer system to transmit said form to acomputer operated for a provider.
 52. The computer system of claim 51wherein the provider is a healthcare provider.
 53. The computer systemof claim 49, wherein the software further causes the computer system toarchive said form as a computer file.
 54. The computer system of claim49, wherein the software further causes the computer system to store atleast some of the data in said form in identifiable fields.
 55. Thecomputer system of claim 41, wherein the at least one identifiable fieldin the second set of identifiable fields comprises an explanation ofbenefits statement, a payment statement, a predetermination statement,or a database.
 56. The computer system of claim 41, wherein the softwarefurther adapts the computer system to transmit at least some of saidsecond set of completed identifiable fields to a computer operated for aprovider.
 57. The computer system of claim 56, wherein the provider is ahealthcare provider.
 58. The computer system of claim 41, wherein thesoftware further adapts the computer system to access at least one ofthe first and the second digital data using the cross-referencing data.59. The computer system of claim 41, wherein the first digital datacomprises data in a first set of N₁ identifiable data fields, and thesecond digital data comprises data in a second set of N₂ identifiabledata fields.
 60. The computer system of claim 41, wherein the digitaldata comprises a computer file.
 61. The computer system of claim 41,wherein at least some of the data included in the first computer file isexcluded from the second computer file.
 62. The computer system of claim61, wherein the excluded data comprises at least some attachment data.63. The computer system of claim 41, wherein the software further causesthe computer system to archive at least some of the digital data as acomputer file.
 64. The computer system of claim 41, wherein the softwarefurther causes the computer system to store at least some of the digitaldata in identifiable fields.
 65. The computer system of claim 41,wherein the received digital data comprises cross-referencing data forassociating the insurance transaction data with the attachment data. 66.The computer system of claim 41, wherein the software further adapts thecomputer system to cross-reference the insurance transaction data andthe attachment data.
 67. The computer system of claim 41, wherein thecross-referencing data comprises at least one identification number. 68.The computer system of claim 41, wherein the cross-referencing datacomprises at least one selected from the group consisting of at leastone identification number, at least some of the insurance transactiondata, healthcare provider document identification data, insurance payerdocument identification data, healthcare payer document identificationdata, healthcare transaction identification data, identification number,healthcare-insurance-claim attachment identification number, and datathat identifies a healthcare encounter.
 69. The computer system of claim41, wherein the computer system is operated for an insurance payer. 70.The computer system of claim 69, wherein the insurance payer is selectedfrom the group consisting of dental insurance payer, medical insurancepayer, healthcare insurance payer, property insurance payer, worker'scompensation insurance payer, and casualty insurance payer.
 71. Thecomputer system of claim 69, wherein the first computer comprises abuffer computer system and the second computer comprises a legacycomputer system.
 72. The computer system of claim 71, wherein the legacycomputer system is a health-insurance-claims management computer system.73. The computer system of claim 71, wherein the attachment data ishealth-insurance-claims attachment data and the insurance transactiondata is health-insurance-claims data.
 74. The computer system of claim71, wherein the buffer computer system is configured by software todisplay at least some of said attachment data on a computer displaydevice.
 75. The computer system of claim 41, wherein the digital data isreceive from a computer system operated for at least one selected fromthe group consisting of a value added service, a provider, an insuranceprovider, a healthcare provider, and a clearinghouse.
 76. The computersystem of claim 41, wherein the insurance transaction data comprisesinformation selected from the group consisting of dental data, medicaldata, healthcare data, worker's compensation data, property insurancetransaction data, and casualty insurance transaction information. 77.The computer system of claim 41, wherein the insurance transaction datacomprises at least one selected from the group consisting ofidentification number, transaction identification data, beneficiaryinformation, beneficiary name, patient data, patient name, healthcareprovider data, healthcare provider name, healthcare provideridentification data, healthcare provider document identification data,healthcare payer identification data, healthcare payer name, healthcarepayer identification number, healthcare payer document identificationdata, healthcare-insurance-claim attachment identification number,description of service provided, date of service, healthcare encounterinformation, prior approval claim data, and worker's compensation data.78. The computer system of claim 41, wherein the attachment datacomprises an attachment selected from a group consisting of a picture, agraph, a sound recording, nonstandard text, a digitized x-ray, anexplanation of benefits, a CT, an MRI, a EKG, a EEG, a strip chart, adigitized video signals, a transcription of operating room notes,supplemental data to a health insurance claim, and additional ASCIItext.
 79. The computer system of claim 41, wherein the software furtheradapts the computer system to transmit the cross-referencing data fromthe first computer to the second computer.
 80. The computer system ofclaim 41, wherein the second data comprises only a portion of the atleast some of the insurance transaction data transmitted from the firstcomputer to the second computer.
 81. A computer implemented method, forprocessing electronic communications, the method comprises the steps of:receiving, from a source external to a computer system, an electroniccommunication comprising first digital data in N₁ identifiable datafields, wherein N₁ is an integer and wherein at least some of the N₁identifiable data fields comprise insurance transaction data and atleast one of the N₁ identifiable data fields comprises attachment datafor at least one attachment stored in memory of a first computer;storing the electronic communication in memory of a second computer;processing the electronic communication by: displaying at least onegraphic user interface screen comprising a set of N₂ identifiable datafields, wherein N₂ is an integer, and the attachment; and determiningsecond digital data to be entered in at least one field in the set of N₂identifiable data fields using at least some of the insurancetransaction data in the set of N₁ identifiable data fields in a logicprocess; wherein the second digital data comprises insurance transactiondata and wherein the second digital data excludes the attachment. 82.The method of claim 81, wherein the attachment data comprises theattachment.
 83. The method of claim 81, wherein the first digital datacomprises patient healthcare data and is received from a healthcareprovider.
 84. The method of claim 81, wherein the first digital datacomprises at least patient identification data and physicianidentification data.
 85. The method of claim 81, further comprising thestep of receiving additional digital data into at least one field in thegraphic user interface.
 86. The method of claim 81, further comprisingthe step of copying the first digital data from at least one field inthe N₁ identifiable data fields into at least one field of the N₂ secondidentifiable data fields.
 87. The method of claim 81, further comprisingthe step of printing at least some of the second digital data.
 88. Themethod of claim 81, wherein the method further comprises the step oftransmitting at least some of the second digital data.
 89. A method,implemented by a server computer, for processing electroniccommunications, the computer system comprising memory and at least onedisplay device, the method comprises the steps of: receiving, from asource external to the computer system, an electronic communicationcomprising digital data in N identifiable data fields, wherein N is aninteger; displaying at least a first and a second graphic user interfacescreen, wherein said first graphic user interface screen comprises afirst set of N₁ identifiable data fields, wherein N₁ is an integer,wherein said second graphic user interface screen comprises a second setof N₂ identifiable data fields, and wherein N₂ is an integer; copyingfirst digital data from at least a first field of the N identifiablefields into at least one of the N₁ identifiable fields; copying seconddigital data from at least a second field of the N identifiable datafields into at least one of the N₂ identifiable data fields; whereindigital data copied into the at least one of the N₂ identifiable fieldsof the second graphic user interface screen excludes at least some ofthe digital data copied into the at least one of the N₁ identifiablefields of the first graphic user interface screen; and determining thedigital data to be displayed in at least one identifiable data field inthe sets of N₁ and N₂ identifiable data fields using at least some ofthe digital data in the set of N identifiable data fields in a logicprocess.
 90. The method of claim 89, wherein the digital data compriseshealthcare data of a patient.
 91. The method of claim 89, wherein thedigital data is received from a healthcare provider.
 92. The method ofclaim 89, wherein the digital data comprises at least patientidentification data and physician identification data.
 93. The method ofclaim 89, further comprising the step of receiving additional digitaldata into at least one field of the set of N₁ identifiable data fieldsor the set of N₂ identifiable data fields from a keyboard or a mouse.94. The method of claim 89, further comprising the step of printing atleast some of the data in the sets of N₁ and N₂ identifiable datafields.
 95. The method of claim 89, wherein the method further comprisesthe step of transmitting at least some of the data in the sets of N₁ andN2 identifiable data fields.
 96. The method of claim 1, furthercomprising: wherein the attachment data comprises at least one selectedfrom a group consisting of a picture, a graph, a sound recording, adigitized x-ray, a CT, an MRI, a EKG, a EEG, a strip chart, an EOB, anda digitized video signal; and wherein the insurance transaction datacomprises alphanumeric data and does not comprise a picture, a graph, asound recording, a digitized x-ray, a CT, an MRI, a EKG, a EEG, a stripchart, an EOB, or a digitized video signal.
 97. The method of claim 1,wherein the attachment data comprises image data, and wherein theinsurance transaction data comprises alphanumeric data and does notcomprise image data.
 98. The method of claim 1, further comprising:wherein the second computer file comprises a request for payment by amedical provider; and wherein the first computer file comprises medicalevidence supporting the request for payment.
 99. The method of claim 1,further comprising: wherein the second computer file comprises a requestfor payment by a medical provider; and wherein the first computer filecomprises medical evidence supporting the request for payment, andwherein the medical evidence is selected in response to a medicalprocedure being claimed for payment in the second computer file. 100.The method of claim 1, further comprising: wherein the attachment datawhich is in identifiable fields comprises at least one selected from agroup consisting of a picture, a graph, a sound recording, a digitizedx-ray, a CT, an MRI, a EKG, a EEG, a strip chart, an EOB, and adigitized video signal; and wherein the insurance transaction data whichis in identifiable fields consists of alphanumeric data.